A Couple questions about "Academic Medicine" and Residency Competitiveness

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Sketcha

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I apologize in advance if these questions have been answered elsewhere in other threads but I couldn't find anything from my searches.

1. This is likely a dumb question, but what exactly is academic medicine (as opposed to private practice). I know that working in academic medicine usually (if not always?) involves working at a hospital associated with a university, but is research always part of the gig if one works in academic medicine? Does one teach classes at the affiliated university if they are in academic medicine? Is it more difficult to get into academic medicine vs. Private practice?

2. I have read a lot about how people are not only aiming to match in the specialty they want for residency, but that they also want to match at competitive programs in their specialty of interest. My question is: why is it so important that people match into MGH vs. a less competitive hospital? I don't mean to ask what is the difference between a top program vs. some small community program, but rather what is the difference between a top tier program and a middle tier program assuming both are large teaching institutions. I would imagine that research opportunities and grant money are a big factor, but is there anything else?

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Academic medicine almost always means the following:
- faculty appointment
- teaching responsibilities (students, residents, fellows, etc)
- less pay than private practice
- generally salaried vs FFS model

Sometimes it means the following:
- protected, compensated non-clinical time for research or administration
- less call if residents and fellows take most of the call
- required inpatient work
 
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I apologize in advance if these questions have been answered elsewhere in other threads but I couldn't find anything from my searches.

1. This is likely a dumb question, but what exactly is academic medicine (as opposed to private practice). I know that working in academic medicine usually (if not always?) involves working at a hospital associated with a university, but is research always part of the gig if one works in academic medicine? Does one teach classes at the affiliated university if they are in academic medicine? Is it more difficult to get into academic medicine vs. Private practice?

2. I have read a lot about how people are not only aiming to match in the specialty they want for residency, but that they also want to match at competitive programs in their specialty of interest. My question is: why is it so important that people match into MGH vs. a less competitive hospital? I don't mean to ask what is the difference between a top program vs. some small community program, but rather what is the difference between a top tier program and a middle tier program assuming both are large teaching institutions. I would imagine that research opportunities and grant money are a big factor, but is there anything else?

Nailed it.
Pretty much this: Funding, networking, research mentors, etc.

Anything Harvard draws the 'ooohhhh shinnnnyyyyy' effect as well. People can say they were trained at harvard. It matter to more people than you'd think.
 
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Don't forget "tenure".

Academic medicine almost always means the following:
- faculty appointment
- teaching responsibilities (students, residents, fellows, etc)
- less pay than private practice
- generally salaried vs FFS model

Sometimes it means the following:
- protected, compensated non-clinical time for research or administration
- less call if residents and fellows take most of the call
- required inpatient work
 
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2. I have read a lot about how people are not only aiming to match in the specialty they want for residency, but that they also want to match at competitive programs in their specialty of interest. My question is: why is it so important that people match into MGH vs. a less competitive hospital? I don't mean to ask what is the difference between a top program vs. some small community program, but rather what is the difference between a top tier program and a middle tier program assuming both are large teaching institutions. I would imagine that research opportunities and grant money are a big factor, but is there anything else?


It may also mean a significant difference in breadth and depth of clinical-to-academic exposure.
 
I apologize in advance if these questions have been answered elsewhere in other threads but I couldn't find anything from my searches.

2. I have read a lot about how people are not only aiming to match in the specialty they want for residency, but that they also want to match at competitive programs in their specialty of interest. My question is: why is it so important that people match into MGH vs. a less competitive hospital? I don't mean to ask what is the difference between a top program vs. some small community program, but rather what is the difference between a top tier program and a middle tier program assuming both are large teaching institutions. I would imagine that research opportunities and grant money are a big factor, but is there anything else?

Although there is some amount of prestige-associated reasons for want to do residency at a top-tier place, the training itself is also a reason for many people. Although you go to med school to become a doctor, and you can make arguments that the better med schools will generally train students to become residents better than the not-as-good med schools, it's really residency where you actually learn to be a doctor in your chosen field. So many people agree that residency is more important than where you go to med school. And even between the top and mid-tier residencies, you will see a difference in the quality of physicians they're producing. This is for many reasons, including A) the faculty will be the best in their fields (and good teachers), B) the residents will see a large number of patients, including C) the sickest and most zebra-like patients who come in to the big/well-known hospitals for the higher-level care they'll receive, and D) the residents will have more autonomy to make their own management decisions so they can become good clinicians while still under the supervision of very good attendings. For some, the protected research time and high quality labs will be a pull as well.
 
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There is very few tenured positions in medical schools these days. Most physicians are expected to "earn their keep" through patient care (or supervision of residents and fellows providing that care) and/ or research.

Much of the "teaching" takes place during interaction with house staff and medical students in patient care settings. The attending physician's academic department earns money for patient care provided by that attending and the trainees under the attending's supervision and the attending's salary is paid by the department. Academic physicians with research funding can get "protected time" to spend doing funded research. Clinical trials sponsored by pharmaceutical companies often pay academic departments as a way of paying for academic clinician's time that would otherwise be spent in patient care (patients and their insurers aren't billed for protocol-driven procedures). A small number of faculty can get jobs with "protected time" for curriculum development, course directing (developing a curriculum and setting up lectures by a dozen or more specialists over a set period), or student mentoring and advising, or other administrative tasks within the department.

Private practice is patient care. There is no teaching or supervision of trainees. There might be administrative tasks done as part of managing your business but you don't get paid for those, they take you away from the part of your business that generates income. (Unless you have people working for you who can bill for patient care under your supervision such as having flocks of nurse practitioners taking care of pediatric outpatients.) If you are a salaried employee of a group practice, your only job may be to show up & care for patients.
 
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Although there is some amount of prestige-associated reasons for want to do residency at a top-tier place, the training itself is also a reason for many people. Although you go to med school to become a doctor, and you can make arguments that the better med schools will generally train students to become residents better than the not-as-good med schools, it's really residency where you actually learn to be a doctor in your chosen field. So many people agree that residency is more important than where you go to med school. And even between the top and mid-tier residencies, you will see a difference in the quality of physicians they're producing. This is for many reasons, including A) the faculty will be the best in their fields (and good teachers), B) the residents will see a large number of patients, including C) the sickest and most zebra-like patients who come in to the big/well-known hospitals for the higher-level care they'll receive, and D) the residents will have more autonomy to make their own management decisions so they can become good clinicians while still under the supervision of very good attendings. For some, the protected research time and high quality labs will be a pull as well.

So I have all of what you've listed above when talking to those higher up the medicine totem pole than me (which is pretty much everyone since I'm just a lowly M1, haha), but I've also heard the following:
A) Bigger hospitals have strong fellowship programs and strong specialty departments so sometimes residents get less of a chance to really run the show since anything complex gets sent off to another department, or taken by the fellows. Smaller hospitals may be more likely to give residents autonomy in managing these types of cases.
B) I know someone who did their fellowship at a high profile hospital that got high profile/ rich patients. He said that many patients insisted on being treated solely by attendings or fellows, so residents, let alone med students, didn't really get to be very hands on with a lot of patients.
C) Top residencies have a focus on producing academics so they select for people with strong research background and emphasize research productivity in residency. Great academic training doesn't always mean great clinical training (of course they're not mutually exclusive!)
D) Top in your field does not mean you are a good teacher. Two separate skill sets, and the former doesn't necessitate the latter.

So while top residencies definitely seem to have advantages in exposure to rare cases and a strong academic focus,I don't think it's necessarily clear that higher ranked residencies will produce better every-day clinicians.
 
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Thanks snowflakes, that was enlightening to hear along with what everyone else has mentioned in this thread.
 
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Does EM kind of not apply to the idea that higher ranked programs will make "better" doctors since you get what comes in for the most part? People don't tend to travel long distances to go to a certain big name emergency dept in a true emergency. Theoretically, you'd get exposed to the zebras too depending on the size of the dept. Right?
 
Does EM kind of not apply to the idea that higher ranked programs will make "better" doctors since you get what comes in for the most part? People don't tend to travel long distances to go to a certain big name emergency dept in a true emergency. Theoretically, you'd get exposed to the zebras too depending on the size of the dept. Right?
The best ER programs are located in "war zones."
 
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