Now that the job market is collapsing, can we have some real discussion on the best residency programs?

[turkeyjerky]

This seems to be contradictory to the consensus on this board for the last several years when this question comes up. I've been following these posts ever since I was a medical student. I followed them again when applying to residencies. I followed them when applying for jobs as a resident. I followed them again when looking for other jobs after residency. I've never seen any attendings on here state you can't get a good job easily if you train at the wrong residency.

Are you basing your diverging opinion on what you predict will happen now that the market is more competitive? I have never encountered a community ED that used name of a residency program to determine whether they wanted to hire a doc or not. That sounds like an exception, not the rule.

I think it's far more nuanced than "if you have a pulse you can walk into whatever job you want" vs "if you don't go to In-N-Out you'll never get a job". Obviously things have changed dramatically in the past several years, especially the past 12 months and they'll continue to change.

I think it's going to get harder and harder to get a job with a good group w/o connections. I'm not saying that people use the name of the residence you attended as a sole criterion to decide whether or not to extend an offer. But if you don't have personal connections to a group, then the reputation of your training matters. Most people would presume that someone coming out of Cincy, Indiana or Denver is well trained. But if you're applying for a position with a group where you don't know anyone and no one there has ever heard of your program, you probably aren't getting the job unless they have no other options.

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[Rekt]

I don’t care what programs are the best, I doubt I’ll end up at them anyways. I wanna know what places to avoid like the plague. Places where ortho does my reductions, ENT won’t let me touch a nosebleed, and NPs/PAs are stealing my lines then my attending dings me on evals for “not being assertive”.

Unfortunately mods will ban us for specifically pointing out bad programs or programs that are hurting EM as a whole. There's plenty of names to shame.

 

[deleted547339]

Unfortunately mods will ban us for specifically pointing out bad programs or programs that are hurting EM as a whole. There's plenty of names to shame.

That’s pretty clearly not true. We are one of the most liberally moderated forums because we tend to behave well, police ourselves and there are a lot of long-time regulars. We even got to (essentially) pick our own moderator from among our ranks.

On another thread, our mod pretty clearly stated the rules:
Stick to objective facts. If you interviewed at a program and a resident told you they feel burned out, you can say that. If the residents all seem tired and they told you they break duty hours, you can say that. If you got a bad vibe somewhere you can say that. If NPs are taking procedures, you can say that. If residents have to go to sim lab to get procedures (other than thoractomy, lateral canthotomy or crics), you can say that. If anesthesia does all trauma airways...Anything that is objectively true is fair game and, by definition, not libelous. You can’t just say “this place sucks” or “everyone there is a d-bag” or “it’s a crappy program.”

Not to mention, I can’t remember the last time someone who was hit clearly a troll was banned. You might get a post edited and a message, but our mod is much more levelheaded than banning a member for saying they don’t like a program.

 

[TheComebacKid]

I don’t care what programs are the best, I doubt I’ll end up at them anyways. I wanna know what places to avoid like the plague. Places where ortho does my reductions, ENT won’t let me touch a nosebleed, and NPs/PAs are stealing my lines then my attending dings me on evals for “not being assertive”.

You are in for a wake up call.

Especially when it comes to ortho. Pretty much the number one universal complaint people have with EM training is poor ortho experience. There are exceptions, and certain programs have better ortho experience than others. But everywhere I interviewed that had an ortho residency had them heavily involved in many, if not all reductions (including where I trained). It's just how it works in academic EM residency programs. I'm sure it's better at some community programs that don't have ortho residents.

I rarely had to ever call ENT for a nosebleed in residency except in rare cases. And NP/PA encroachment in residency is now starting to become a problem, but I would say is still fairly rare at most places.

Also you clearly have a ways to go if you are excited to manage a nosebleed. I'll gladly have ENT manage those any days. One of the worst chief complaints ever.

 

[TheComebacKid]

This seems to be contradictory to the consensus on this board for the last several years when this question comes up. I've been following these posts ever since I was a medical student. I followed them again when applying to residencies. I followed them when applying for jobs as a resident. I followed them again when looking for other jobs after residency. I've never seen any attendings on here state you can't get a good job easily if you train at the wrong residency.

Are you basing your diverging opinion on what you predict will happen now that the market is more competitive? I have never encountered a community ED that used name of a residency program to determine whether they wanted to hire a doc or not. That sounds like an exception, not the rule.

After having just gone through the job search, I can tell you that the location of the training program matters more, in my opinion than the reputation of it.

If you want a job in NY, the best bet is to train at a NY residency program. Hopefully you will realize that NY is a terrible place for multiple reasons, but if you don't, then train at a NY program. Any of the major programs there are all fine, although some might be ranked higher on Doximity or some other arbitrary list, it won't make a difference. If you want to end up in Denver, it doesn't matter how great the NY program you trained at is, Denver Health grads will have a huge leg up.

I trained in two different states, one for residency and one for fellowship. I signed on to a position in the same state as I did my fellowship. When I asked my residency program to put in a good word for me, they said, "we'll try, but just be aware, we don't know that many people in your new state, you should ask your fellowship folks." When my fellowship made phone calls, the interviews and job offers started flowing in.

Location is king. Especially in a tight market. Even in the community. If you want to live in some no-name/unpopular place, having a pulse is all that matters. If you want to live in a competitive job market based on location, I highly recommend that you train in that area. That's not to say that it can't happen if you train elsewhere, but it's way easier in my personal experience.

 

[Rekt]

Just have to know what you want from a program. Going to an academic center you're sacrificing a lot. No ortho where I'm at. I got >30 reductions (exceeding requirements) my intern year alone and still going strong. 4 PTAs my intern year as well. Imo there's no benefit going to be a tertiary care center for EM.

 

[skougess]

Just have to know what you want from a program. Going to an academic center you're sacrificing a lot. No ortho where I'm at. I got >30 reductions (exceeding requirements) my intern year alone and still going strong. 4 PTAs my intern year as well. Imo there's no benefit going to be a tertiary care center for EM.

Eh I’m biased because I go to an academic residency but I’m very glad I’m training at a tertiary center. We do a few community months and the tertiary patients are just SO much more complex/annoying than in the community. Even the really sick ones (which the community site had plenty of) were weirdly way more straight forward. It’s like training against an NFL team and then you show up on game day to a Pee Wee team.

I was worried about ortho experience too until I did about my third reduction in the community and I was pretty over it. If they are non surgical, you’re just trying to get them “good enough” so they can be seen by ortho as an outpatient.

 

[Franzd'Epinay]

Just have to know what you want from a program. Going to an academic center you're sacrificing a lot. No ortho where I'm at. I got >30 reductions (exceeding requirements) my intern year alone and still going strong. 4 PTAs my intern year as well. Imo there's no benefit going to be a tertiary care center for EM.

I think tertiary centers are overrated by med students for residency, but there is definitely benefit in having some experience in level I trauma centers and pediatric EDs (which are usually associated with said tertiary centers). Super complex medical patients can sometimes be good learning experiences, but I think the level I trauma and pediatric ED components are more helpful longerm.

 

[turkeyjerky]

Some good recent posts on quality of training. I think a tertiary care community hospital is probably the sweet spot. You definitely don't want mandatory ortho or other consults for certain conditions, but you want exposure to medically complex patients. Being at a level 1 trauma center that does Ecmo, LVADs and Transplants w/ an affliated peds hospital is ideal. You want sick complex patients coming in, but you want the consultants you're calling to be attendings sleeping at home.

I trained at such a place. Unfortunately, it's not well known outside of the region, so didn't help too much in my recent job search.

 

[EMhawkeye]

There are also the hidden gem level 2's that function as level one's.

 

[GeneralVeers]

There are also the hidden gem level 2's that function as level one's.

Functionally there's no difference except a Level 1 has a formal trauma education program. Patient care should be equivalent.

 

[Fox800]

There are also the hidden gem level 2's that function as level one's.

Yep. These get overlooked, and you get a good sense of community practice.

 

[GeneralVeers]

Yep. These get overlooked, and you get a good sense of community practice.

Level 2 almost provides better training, because in general you are not competing with surgical residents for procedures. I did my residency training at primarily level 2 sites, and it was basically 1 on 1 with the trauma surgeon for the entire call period.

 

[KGflyboy]

Level 2 almost provides better training, because in general you are not competing with surgical residents for procedures. I did my residency training at primarily level 2 sites, and it was basically 1 on 1 with the trauma surgeon for the entire call period.

Agreed. I auditioned at a level 2 trauma center with no surgery residents. The EM residents did a ton of procedures.

I did 2 large bore chest tubes that month.

 

[turkeyjerky]

Agreed. I auditioned at a level 2 trauma center with no surgery residents. The EM residents did a ton of procedures.

I did 2 large bore chest tubes that month.

And you've just demonstrated one of the downsides....failure to keep up with best practices

 

[KGflyboy]

And you've just demonstrated one of the downsides....failure to keep up with best practices

Not really... Surgical chest tubes are still the "go to" for hemothoraces... Even the academic place I currently work at.

Also... I was talking about medical school. That was several years ago.

I think you are referring to the shift to pig tails or PERC tubes that has been occuring for the last few years. Most people seem to be using those for pneumothoraces and pleural effusions. I haven't seen anybody in my area use those for traumatic hemothoraces. Maybe that's regional... I don't know. But I haven't seen any recommendations that we should replace all surgical chest tubes with pig tails.

We have decreased the size of tube though. We typically use a 21 for most things now. I will never use a 40 again in my career if I can avoid it. Those are just torture for no good reason in most cases.

If you have any practice guidelines I'm not yet aware of, please share them!

 

[turkeyjerky]

Not really... Surgical chest tubes are still the "go to" for hemothoraces... Even the academic place I currently work at.

Also... I was talking about medical school. That was several years ago.

I think you are referring to the shift to pig tails or PERC tubes that has been occuring for the last few years. Most people seem to be using those for pneumothoraces and pleural effusions. I haven't seen anybody in my area use those for traumatic hemothoraces. Maybe that's regional... I don't know. But I haven't seen any recommendations that we should replace all surgical chest tubes with pig tails.

We have decreased the size of tube though. We typically use a 21 for most things now.

My bad, I was really just referring specifically to 'large-bore'.

 

[KGflyboy]

My bad, I was really just referring specifically to 'large-bore'.

Yes... Probably poor terminology on my behalf. I was equating large bore with surgical chest tubes. I should be more specific. It sounds like we have a similar understanding of chest tube selection and utilization.

At one of my hospitals we don't even stock the super sized tubes in the ED anymore.

Although I do keep finding the trocar tubes in my trauma bays... Despite the fact nobody around here uses them. But that's another story.

 

[The Knife & Gun Club]

Just have to know what you want from a program. Going to an academic center you're sacrificing a lot. No ortho where I'm at. I got >30 reductions (exceeding requirements) my intern year alone and still going strong. 4 PTAs my intern year as well. Imo there's no benefit going to be a tertiary care center for EM.

Some good recent posts on quality of training. I think a tertiary care community hospital is probably the sweet spot. You definitely don't want mandatory ortho or other consults for certain conditions, but you want exposure to medically complex patients. Being at a level 1 trauma center that does Ecmo, LVADs and Transplants w/ an affliated peds hospital is ideal. You want sick complex patients coming in, but you want the consultants you're calling to be attendings sleeping at home.

I trained at such a place. Unfortunately, it's not well known outside of the region, so didn't help too much in my recent job search.

I’m sure you both trained at Great places but I think the setup you’re describing is pretty rare.

By far the majority of places seeing a solid volume with complex and speciality patients are going to be academic centers.

Maybe not ultra-academic hospitals like Stanford or MGH, but even shops like Carolinas which aren’t “academic” will still have surgery residents and ortho residents with whom you need to compete for procedures.

 

[WilcoWorld]

Yes... Probably poor terminology on my behalf. I was equating large bore with surgical chest tubes. I should be more specific. It sounds like we have a similar understanding of chest tube selection and utilization.

At one of my hospitals we don't even stock the super sized tubes in the ED anymore.

Although I do keep finding the trocar tubes in my trauma bays... Despite the fact nobody around here uses them. But that's another story.

I call the "super sized tubes" garden hoses. OUCH

 

[EMhawkeye]

I find the idea of a pigtail in a traumatic hemothorax funny. Like bringing a butter knife to a gun fight.

 

[turkeyjerky]

I’m sure you both trained at Great places but I think the setup you’re describing is pretty rare.

By far the majority of places seeing a solid volume with complex and speciality patients are going to be academic centers.

Maybe not ultra-academic hospitals like Stanford or MGH, but even shops like Carolinas which aren’t “academic” will still have surgery residents and ortho residents with whom you need to compete for procedures.

I think Carolinas would probably fit the bill. I mean, we had other residents at our hospital, but didn't really have to compete for procedures. I think it was a community affliate for an ortho residency, but they were just there to be in the OR, never saw them in the ED.

 

[Torsion]

There is a enough ortho trauma coming through our hospital that the orthopedic residents are more than happy to have us take a stab at more straightforward reductions before calling them, especially later in the year when the ortho terns have had their fill. The other component is that there is generally an EM intern on the ortho service at all times, so if you consult ortho for a reduction you are actually helping your interns get their numbers.

 

[deleted547339]

I call the "super sized tubes" garden hoses. OUCH

No, those are the ecmo cannulas.

 

[WilcoWorld]

Now it's made the Washington Post.

 

[Dr Mantis Toboggan]

Now it's made the Washington Post.

Why does it annoy me so much that this Murfreesboro TN residency is called UT Nashville?

It’s not in Nashville. Nor is it in a contiguous suburb. It’s a completely different town in middle TN.

 

[wamcp]

Now it's made the Washington Post.

Damn.
For internal medicine, there were 8116 IM residency positions offered in the match in 2019. Of internal med grads, 4909 went into fellowship in 2019. Then nearly 50% of those who didn't go to fellowship chose primary care, and the remainder go into hospitalist work. Lots of relief valves for everyone.

While you have a near doubling of EM residents since 2008, but really only one place to work...

 

[The Knife & Gun Club]

Why does it annoy me so much that this Murfreesboro TN residency is called UT Nashville?

It’s not in Nashville. Nor is it in a contiguous suburb. It’s a completely different town in middle TN.

This came up when my wife and I looked at couple matching there.

UT Nashville is the GME consortium. Most of their residencies, like OB and Medicine, were based out of the main hospital in their system which is in downtown Nashville (St Thomas Midtown). That’s also the main clinical site for Med students at UTHSC-Nashville.

The EM program is based out of the community hospital in Murfreesboro (St Thomas Rutherford) for a variety of reasons - but the larger GME architecture is still based in Nashville. Hence the name.

Lots of programs do this - for example UMiami has a general surgery residency in west palm beach, over an hour away from the main hospital. New York Presbyterian has an EM Residency in Queens.

Plus you’re correct, I’m sure there’s an aspect of making it more salable which the program finds beneficial.

 

[CaptainZeki]

As many of us MS4s are starting to make rank lists and also consider which interviews to drop vs keep, given the job market, it would be really helpful to hear some advice on what programs are the best for finding good employment in the future.

If you look at basically any time the idea of a "best EM program" is discussed, these common phrases are just repeated:
"go where you want to live"
"does not matter at all"
"In before In-N-Out"
"to get hired you just need a pulse"

Of course, with midlevel creep, residency expansions, CMG takeovers, the future (as is often discussed heavily on this forum) is not looking too bright for new EM grads, and will likely be worse when I graduate residency in ~2025. So when there is a glut of EM docs, or god forbid a new model like anesthesia's 1 doc to 4 midlevels, it almost certainly will matter where you trained, perhaps especially to SDGs.

So other than avoiding HCA and brand new programs, can we hear some advice on what programs really are the best? Assume no specific interest in working in any particular geographic market after graduation, so whatever program would set you up the best nationally.

Can someone clarify why avoid HCA?

 

[RustedFox]

Can someone clarify why avoid HCA?

HCA is pure evil.

 

[CaptainZeki]

HCA is pure evil.

Care to expand further

 

[Apollyon]

Care to expand further

The Hospital Corporation of America. If that doesn't clue you in yet, stand by. What do corporations do? They make money, including by cutting corners. They have sponsored several new residency programs, at hospitals that barely scrape the very, very minimal floor of requirements. This is fact. It is not yet clear as to the quality of graduates. The belief among some is that they are creating EM docs to staff their own hospitals. Go back to my first statement (it's not a formal sentence).

If yours is a legitimate question, there's your answer. If you already searched, or just read the forums, and already knew this, and just wanted to get a rise, then, bad form.

 

[RustedFox]

The Hospital Corporation of America. If that doesn't clue you in yet, attend by. What do corporations do? They make money, including by cutting corners. They have sponsored several new residency programs, at hospitals that barely scrape the very, very minimal floor of requirements. This is fact. It is not yet clear as to the quality of graduates. The belief among some is that they are creating EM docs to staff their own hospitals. Go back to my first statement (it's not a formal sentence).

If yours is a legitimate question, there's your answer. If you already searched, or just read the forums, and already knew this, and just wanted to get a rise, then, bad form.

Post history suggests that he's a pre-clinical student.

 

[CaptainZeki]

Post history suggests that he's a pre-clinical student.

Yea I’m a MS1 and still learning about various residency programs. But this is good to know! Thanks

 

[partypantss]

Is there a significant difference in clout between like, UPMC Pittsburgh and Detroit receiving hospital? I'm someone that has no clue what area of the country I want to ultimately settle down in, (if I don't just move to Australia or something that is) so I want as many doors open as possible. I seemed to like the people at DRH more, but if UPMC really opens more doors, I may go with them for my #1.

 

[Rekt]

Is there a significant difference in clout between like, UPMC Pittsburgh and Detroit receiving hospital? I'm someone that has no clue what area of the country I want to ultimately settle down in, (if I don't just move to Australia or something that is) so I want as many doors open as possible. I seemed to like the people at DRH more, but if UPMC really opens more doors, I may go with them for my #1.

DRH has no name in EM if you're looking for "clout", which is incredibly meaningless anyway. Your number one should be where you'll be most happy if you've already made the mistake of staying in EM.

 

[deleted547339]

Can someone clarify why avoid HCA?

You must be new here....

 

[CaptainZeki]

You must be new here....

Yea I’m a MS1. Still learning.

 

[deleted547339]

Yea I’m a MS1. Still learning.

They’re the worst. The worst. Their goal is maximize profit and everything else is just an obstacle.

 

[CaptainZeki]

They’re the worst. The worst. Their goal is maximize profit and everything else is just an obstacle.

Yea I figured that much from what people are sharing on this post. Mind sharing any articles so I can learn further?

 

[Fox800]

The search feature. It’s a thing.

Yea I figured that much from what people are sharing on this post. Mind sharing any articles so I can learn further?

 

[The Knife & Gun Club]

Yea I figured that much from what people are sharing on this post. Mind sharing any articles so I can learn further?

If you close your eyes and click a random thread chances are you’ll find pages and pages of discussion on this topic.

Usually starts around page 2, once the initial question has been answered but people want to keep bitching until a mod comes in and locks the thread.

 

[Rekt]

If you close your eyes and click a random thread chances are you’ll find pages and pages of discussion on this topic.

Usually starts around page 2, once the initial question has been answered but people want to keep bitching until a mod comes in and locks the thread.

I mean, knock on all the complaining you want, but it's the reason you probably won't have a job in two years, especially in FL at least. I've seen FL dumping a bunch of pgy3 contracts this week. If HCA didn't flood the area there would be a lot less issue, even with covid.

 

[KGflyboy]

I mean, knock on all the complaining you want, but it's the reason you probably won't have a job in two years, especially in FL at least. I've seen FL dumping a bunch of pgy3 contracts this week. If HCA didn't flood the area there would be a lot less issue, even with covid.

This "dumping of pgy3 contracts" is what makes the HCA problem so painfully obvious to us. I wish it was more obvious to everyone else.

HCA is rapidly creating residency programs in order to provide cheap labor and dilute the applicant pool for attending jobs, thus driving down wages at the same time current PGY3s are having their first contracts canceled. The job market just cannot support this expansion.

Beyond us complaining on SDN... Nobody seems to care or do anything about it. It's insane.

 

[Dr Mantis Toboggan]

The powers that be would love to have an abundance of neurosurgeons, urologists etc.

The difference is those doctors don’t open up residencies in crap hospitals without the needed procedural experience and their residency accreditation boards have standards.

I can’t fully blame HCA for doing what they do. They are a for profit enterprise trying to maximize their revenues and decrease their costs. I can and do blame our RRC that allows anyone to have a program that wants one apparently.

 

[WilcoWorld]

Is there a significant difference in clout between like, UPMC Pittsburgh and Detroit receiving hospital? I'm someone that has no clue what area of the country I want to ultimately settle down in, (if I don't just move to Australia or something that is) so I want as many doors open as possible. I seemed to like the people at DRH more, but if UPMC really opens more doors, I may go with them for my #1.

As someone only familiar with the programs from their national reputation - I think they're very comparable. So if you aren't focused on either of their geographic areas, go with the personal fit.

 

[Bougiebuster]

Yea I’m a MS1. Still learning.

The goal of a residency program is to teach you. The goal of these HCAs is profit. Those do not align. With some exceptions - most CMG run EDs are there to maximize profit, move the meat, and staff a large number of MLPs (who have already started competing for procedures/etc). The attendings there are not teaching faculty that care about training residents, they want you to also move the meat and help their bottom line, residents are cheap labor for hospitals.

Could you get adequate clinical training at one of these sites? Perhaps. But the quality of training, the complete lack of a didactic curricula/sim training/research/etc is astounding.

As far as which programs to avoid/go to. The majority stance on this forum is go where you find a best fit and best geographically. That being said, most of the "powerhouse" programs or most established ones have a large alumni base that can significantly help you get a job in tight markets from networking.

 

[RustedFox]

The goal of a residency program is to teach you. The goal of these HCAs is profit. Those do not align. With some exceptions - most CMG run EDs are there to maximize profit, move the meat, and staff a large number of MLPs (who have already started competing for procedures/etc). The attendings there are not teaching faculty that care about training residents, they want you to also move the meat and help their bottom line, residents are cheap labor for hospitals.

Could you get adequate clinical training at one of these sites? Perhaps. But the quality of training, the complete lack of a didactic curricula/sim training/research/etc is astounding.

As far as which programs to avoid/go to. The majority stance on this forum is go where you find a best fit and best geographically. That being said, most of the "powerhouse" programs or most established ones have a large alumni base that can significantly help you get a job in tight markets from networking.

Y-you... you said it. You said the P-word.

 

[KGflyboy]

As far as which programs to avoid/go to. The majority stance on this forum is go where you find a best fit and best geographically. That being said, most of the "powerhouse" programs or most established ones have a large alumni base that can significantly help you get a job in tight markets from networking.

This.

Despite multiple people who have been through the match process, finished residency, and worked in academic and community settings emphasizing this advice for selecting a residency, there is still no shortage of medical students who won't believe it (their fault) or are getting only bad advice (not their fault) from their med school advisers. They continue to use "powerhouse" rankings and disregard the advice about geography and personal fit only to realize how much those factors matter when it's too late.

 

[Dr Mantis Toboggan]

As someone only familiar with the programs from their national reputation - I think they're very comparable. So if you aren't focused on either of their geographic areas, go with the personal fit.

Yeah if it’s a tie maybe give Pitt the nod, Big Ben has 2 rings. Stafford 0.