Small vs Big Cali programs

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sunsfan82

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Hey all,

I'm an MS4 just finishing up interviews. Arizona raised, medical school on the west coast. I'm looking to end up in cali. Pretty competitive applicant with great sloes and scores. I've had some trouble deciding which programs to put at the top of the list as they are very different programs. I've searched some previous threads that may have touched on the "big picture" of big names and/or good programs and the smaller and/or "cushier" residency programs.

Harbor UCLA, USC and the smaller ones being UCI and Kaiser SD. I liked the vibes better and the lifestyle of the 3 year programs (UCI and Kaiser) better, but I can't help but feel Harbor and USC would open more doors. As far as future plans, I see myself 85% sure in the community setting. I've never been a person to relish in names and prestige, but I just don't want to shoot myself in the foot. From what I've seen all cali programs are great.

Just wanted to get some of your opinions. Thanks!

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This is your chance to learn and pick the minds of your attendings for the next 3-4 years. Go to the place where you will see the highest volume of the sickest patients. You can learn the obscure lower acuity stuff later as it comes. But when the critical patients roll in, you need to know exactly what to do. You want a poor, unhealthy, uninsured population to train in. Because that will be the sickest, with the most out of control comorbidities, and the best examples of ridiculously sick patients that stand out in your mind throughout your career.

When you are done, you can choose what type of practice you want. But you'll never be able to replicate a nitty-gritty residency experience.
 
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Thanks for the advice. Just to play devils advocate, sick patients still come to these hospitals, even Kaiser (110k visits/year) Very old population. Is the county pop necessary?
 
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Thanks for the advice. Just to play devils advocate, sick patients still come to these hospitals, even Kaiser (110k visits/year) Very old population. Is the county pop necessary?

Good thought. Everyone eventually gets sick and dies, right?

Here's the difference.

In a patient demographics where people have access to health care, there will be lots of 70-90 year old pts with well managed hypertension, diabetes, and CAD. When they come into the hospital, they will have been much better managed, and perhaps symptoms more mild. Yes there will be sick critical ones too. Yes they all die.

In a county population with poor access to health care, you'll see poorly managed out-of-control diseases in old patients, young patients, and everything in between. You'll see disease at its fullest within the entire spectrum of human life. Not just 30 year olds with moderate asthma and the end game SNF UTIs, moderate CHF exacerbations and acute on chronic renal failures.

My 2 cents. Try to link this with a program where the residents are happy and engaged and you've hit gold.
 
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This is your chance to learn and pick the minds of your attendings for the next 3-4 years. Go to the place where you will see the highest volume of the sickest patients. You can learn the obscure lower acuity stuff later as it comes. But when the critical patients roll in, you need to know exactly what to do. You want a poor, unhealthy, uninsured population to train in. Because that will be the sickest, with the most out of control comorbidities, and the best examples of ridiculously sick patients that stand out in your mind throughout your career.

When you are done, you can choose what type of practice you want. But you'll never be able to replicate a nitty-gritty residency experience.

I think it is worthwhile hearing a countering point to this. Seeing sick patients is important, there's no doubt. That was my big beef with the military program where I was staff for a few years after residency-nobody ever got intubated in that ED. Seriously. Maybe once in the three years worth of shifts I had. That's a problem.

BUT.....

I don't think you need to be at a county hospital where everyone is poor and uninsured. Any good program is going to have enough poor and uninsured patients that you will learn how to take care of those folks. Plus, those sorts of places can be major time sucks. You spend your time learning how to deal with programs for the poor, managing chronic issues for people with no PCP, and if the place is underfunded like many county places, maybe even drawing blood and pushing wheelchairs. Sometimes a better staffed ivory tower type place has its advantages.

The other big problem I see with people going to county programs and then coming directly into a community ED is they have no concept whatsoever of how to treat normal people appropriately. They assume anyone who comes into an ED is a dirtbag, that's its okay to leave someone in the waiting room for four hours, and that those darn patients should be grateful for the opportunity to wait four hours to pay $2000 for your 10 minutes and a few overpriced tests. They get tons of complaints from patients, consultants, and nursing staff. Now most emergency docs are smart enough to learn that customer service stuff very quickly, but a few never really figure it out.

Those "little things" are also important to learn. At my program we worked 2 or 3 shifts a month in the urgent care during our intern year. That side of the ED was staffed by FPs. I learned a ton of stuff about the little things that I still use. The little things will come in to your community ED, and if you know how to take care of them, you'll do a lot more good.

I rotated at UCI on an US elective as a resident. There were plenty of "county-type" patients there.
 
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Hey all,

I'm an MS4 just finishing up interviews. Arizona raised, medical school on the west coast. I'm looking to end up in cali. Pretty competitive applicant with great sloes and scores. I've had some trouble deciding which programs to put at the top of the list as they are very different programs. I've searched some previous threads that may have touched on the "big picture" of big names and/or good programs and the smaller and/or "cushier" residency programs.

Harbor UCLA, USC and the smaller ones being UCI and Kaiser SD. I liked the vibes better and the lifestyle of the 3 year programs (UCI and Kaiser) better, but I can't help but feel Harbor and USC would open more doors. As far as future plans, I see myself 85% sure in the community setting. I've never been a person to relish in names and prestige, but I just don't want to shoot myself in the foot. From what I've seen all cali programs are great.

Just wanted to get some of your opinions. Thanks!
I am an MS4 like yourself so take my advice with a grain of salt. I rotated at USC and interviewed at those programs except Kaiser. USC and Harbor are very different programs than the other two. Harbor and USC are quintessential county programs and you have to be prepared to work with that patient population all four years. The residents I saw there were outstanding clinicians but they work very hard - 12 hours at LA-USC is no joke. You should also consider how you learn. At UCI the attendings are very hands-on with the residents and you get great one-to-one training. At USC and Harbor the residents seemed to lean more heavily on their seniors for teaching. If you like to always have that attending support then doing jail shifts at LA county where you are on your own for much of the shift (there is obviously an attending in charge that will round on the patients) is probably not going to be for you. People who are more independent, however, will love that autonomy. I agree with @The White Coat Investor about UCI in the sense that many of the patients are underserved. While the volume overall is less there are fewer residents so you will be busy. All programs in California are great and will get you jobs in the area if thats what you want.
 
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I am an MS4 like yourself so take my advice with a grain of salt. I rotated at USC and interviewed at the other places except Kaiser. USC and Harbor are very different programs than the other two. Harbor and USC are quintessential county programs and you have to be prepared to work with that patient population all four years. The residents I worked with were outstanding clinicians but they work very hard - 12 hours at LA-USC is no joke. You should also consider how you learn. At UCI the attendings are very hands-on with the residents and you get great one-to-one training. At USC and Harbor the residents seemed to lean more heavily on their seniors for teaching. If you like to always have that attending support then doing jail shifts at LA county where you are on your own for much of the shift (there is obviously an attending in charge that will round on the patients) is probably not going to be for you. People who are more independent, however, will love that autonomy. I agree with @The White Coat Investor about UCI in the sense that many of the patients are underserved. While the volume overall is less there are fewer residents so you will be busy. All programs in California are great and will get you jobs in the area if thats what you want.

I can't speak for LAC+USC, but I trained at Harbor and am faculty there, and there is definitely a lot of teaching from the attendings. We have sit-down rounds between shifts where we do dedicated teaching, review interesting cases, and also teach a lot on shift. Also, our shifts are 9-10 hours which are very manageable especially with the rounds. As a PGY-4 at Harbor it is true you will get less attending interaction -- but only if you don't want it. They will be able to discharge patients on their own without talking to us, but we are of course always there as a lifeline/consultant if necessary. All other years, all patients are staffed with the attending though. I could not recommend highly enough the residency program at Harbor; it was a phenomenal experience and the training was/is outstanding.
 
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What about UCLA/Olive View, does it have a bit of both county and community??
 
What about UCLA/Olive View, does it have a bit of both county and community??

Ronald Reagan is about as academic as it gets while Olive View is your typical county hospital.
 
Any red flags to look for in a newer program like kaiser?
 
Any thoughts on UCLA/olive view vs harbor in terms of job placement and opportunities in LA? Also, thoughts on UCLA/olive view vs some of the other bigger academic power houses in cali like Stanford and ucsf in terms of opportunities afterwards and job placement primarily in Southern California?
 
Any thoughts on UCLA/olive view vs harbor in terms of job placement and opportunities in LA? Also, thoughts on UCLA/olive view vs some of the other bigger academic power houses in cali like Stanford and ucsf in terms of opportunities afterwards and job placement primarily in Southern California?
Equivalent
 
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Any thoughts on UCLA/olive view vs harbor in terms of job placement and opportunities in LA? Also, thoughts on UCLA/olive view vs some of the other bigger academic power houses in cali like Stanford and ucsf in terms of opportunities afterwards and job placement primarily in Southern California?

If you want to work in LA it really doesn't matter which California program you go to. I'm at a four year program in Cali and our seniors routinely get the jobs in the cities they want. While it's fairly wide open, you are gonna be paid commensurate with the desirability of the location.
 
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I think it is worthwhile hearing a countering point to this. Seeing sick patients is important, there's no doubt. That was my big beef with the military program where I was staff for a few years after residency-nobody ever got intubated in that ED. Seriously. Maybe once in the three years worth of shifts I had. That's a problem.

BUT.....

I don't think you need to be at a county hospital where everyone is poor and uninsured. Any good program is going to have enough poor and uninsured patients that you will learn how to take care of those folks. Plus, those sorts of places can be major time sucks. You spend your time learning how to deal with programs for the poor, managing chronic issues for people with no PCP, and if the place is underfunded like many county places, maybe even drawing blood and pushing wheelchairs. Sometimes a better staffed ivory tower type place has its advantages.

The other big problem I see with people going to county programs and then coming directly into a community ED is they have no concept whatsoever of how to treat normal people appropriately. They assume anyone who comes into an ED is a dirtbag, that's its okay to leave someone in the waiting room for four hours, and that those darn patients should be grateful for the opportunity to wait four hours to pay $2000 for your 10 minutes and a few overpriced tests. They get tons of complaints from patients, consultants, and nursing staff. Now most emergency docs are smart enough to learn that customer service stuff very quickly, but a few never really figure it out.

Those "little things" are also important to learn. At my program we worked 2 or 3 shifts a month in the urgent care during our intern year. That side of the ED was staffed by FPs. I learned a ton of stuff about the little things that I still use. The little things will come in to your community ED, and if you know how to take care of them, you'll do a lot more good.

I rotated at UCI on an US elective as a resident. There were plenty of "county-type" patients there.

I agree with all of this. I trained at a large inner city program with tons of trauma exposure. I found going to the community somewhat difficult afterward, because I felt I was never taught how to discharge a patient. On top of what you said, I could no longer admit every single 19 year old with panic attack to rule out acs (I'm exaggerating obviously) or get an MRI at 0200 for a chronic back pain patient who swore there was something different. Yes You must consider nausea as a possible anginal equivalent, but in residency some attendings will admit everyone for any possible anginal equivalent.

One more thing, it bothers me that "standard of care" is determined by lawyers and academic attendants who work 400 clinical hours per year (and no I've never been sued haha).

Anyway, I think you will get out of residency what you put into residency. If you try to be agressive and see as many patients as possible, and you do plenty of reading, you can succeed in EM, regardless of program.
 
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Any thoughts on UCLA/olive view vs harbor in terms of job placement and opportunities in LA? Also, thoughts on UCLA/olive view vs some of the other bigger academic power houses in cali like Stanford and ucsf in terms of opportunities afterwards and job placement primarily in Southern California?

UCLA-Olive View is considered much more academic than Stanford (which is three years and so not really a true 'academic' setting) and USCF, which is very new still. The locus of academic EM in California is at UCLA, hard stop. About half the editorial staff of Annals is there. If you have any sense of wanting to do academics, that is the place you should be trying to go. Other programs are great too, but UCLA is the academic locus of EM in California (and arguably the country).
 
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UCLA-Olive View is considered much more academic than Stanford (which is three years and so not really a true 'academic' setting) and USCF, which is very new still. The locus of academic EM in California is at UCLA, hard stop. About half the editorial staff of Annals is there. If you have any sense of wanting to do academics, that is the place you should be trying to go. Other programs are great too, but UCLA is the academic locus of EM in California (and arguably the country).

@hotdogger, are you an attending, resident, or student?

What makes you say only four-year programs can be academic?

Also, Stanford is now a four-year program; they probably got tired of debunking the above (false) idea in applicants. I'm sure they would take issue if someone said that they are new to academic emergency medicine.
 
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UCLA-Olive View is considered much more academic than Stanford (which is three years and so not really a true 'academic' setting) and USCF, which is very new still. The locus of academic EM in California is at UCLA, hard stop. About half the editorial staff of Annals is there. If you have any sense of wanting to do academics, that is the place you should be trying to go. Other programs are great too, but UCLA is the academic locus of EM in California (and arguably the country).

I love UCLA, but c'mon man...THE academic locus for EM in the country? Nawwwww...
It's one of them for sure. I would say, as of now, it is roughly equivalent with UCSF and Stanford. UCSD is also an academic powerhouse in EM.
 
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@hotdogger, are you an attending, resident, or student?

What makes you say only four-year programs can be academic?

Also, Stanford is now a four-year program; they probably got tired of debunking the above (false) idea in applicants. I'm sure they would take issue if someone said that they are new to academic emergency medicine.

Let's be honest--4 year programs are generally a lot more academic... (allow more time for longitudinal work).
 
Speaking of UCLA...

Apparently they're doing a whole lot of research and not a whole lot of intubations.

 
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Let's be honest--4 year programs are generally a lot more academic... (allow more time for longitudinal work).

What about the three year UCs? UC Irvine and Davis seem to be pretty academic, especially US at Irvine and Peds EM at Davis with PECARN.
 
What about the three year UCs? UC Irvine and Davis seem to be pretty academic, especially US at Irvine and Peds EM at Davis with PECARN.

Those are great academic institutions, and Vanderbilt, UoC, Pitt are other academic 3 year programs, many of which I interviewed at. That's why I wrote "generally". Having spoken to many faculty mentors, I get the sense you have more time to pursue and grow a niche and produce significant research/body of work over 4 years with close mentorship and generally more financial resources.
 
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I think it is worthwhile hearing a countering point to this. Seeing sick patients is important, there's no doubt. That was my big beef with the military program where I was staff for a few years after residency-nobody ever got intubated in that ED. Seriously. Maybe once in the three years worth of shifts I had. That's a problem.

BUT.....

I don't think you need to be at a county hospital where everyone is poor and uninsured. Any good program is going to have enough poor and uninsured patients that you will learn how to take care of those folks. Plus, those sorts of places can be major time sucks. You spend your time learning how to deal with programs for the poor, managing chronic issues for people with no PCP, and if the place is underfunded like many county places, maybe even drawing blood and pushing wheelchairs. Sometimes a better staffed ivory tower type place has its advantages.

The other big problem I see with people going to county programs and then coming directly into a community ED is they have no concept whatsoever of how to treat normal people appropriately. They assume anyone who comes into an ED is a dirtbag, that's its okay to leave someone in the waiting room for four hours, and that those darn patients should be grateful for the opportunity to wait four hours to pay $2000 for your 10 minutes and a few overpriced tests. They get tons of complaints from patients, consultants, and nursing staff. Now most emergency docs are smart enough to learn that customer service stuff very quickly, but a few never really figure it out.

Those "little things" are also important to learn. At my program we worked 2 or 3 shifts a month in the urgent care during our intern year. That side of the ED was staffed by FPs. I learned a ton of stuff about the little things that I still use. The little things will come in to your community ED, and if you know how to take care of them, you'll do a lot more good.

I rotated at UCI on an US elective as a resident. There were plenty of "county-type" patients there.

I think this is a larger issue than most realize. Some of these county programs like Jacobi, Lincoln, UNM, and SUNY Downstate just NEVER rotate at an ED where customer service matters, and their attendings have no clue because they have lived their whole lives within such a system. If you are going county, I would advise looking at a program like Hennepin that rotate residents through a private hospital. Anyone can learn medicine. It's learning to work in a tough customer service environment that's the challenge. Most of those grads from places like Downstate go into academia/work at county forever. If that's your game, great, but know it before you enter.
 
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Those are great academic institutions, and Vanderbilt, UoC, Pitt are other academic 3 year programs, many of which I interviewed at. That's why I wrote "generally". Having spoken to many faculty mentors, I get the sense you have more time to pursue and grow a niche and produce significant research/body of work over 4 years with close mentorship and generally more financial resources.

Yeah, my point is that '4 years means academic' isn't a great generalization in California. Not only for those UCs, but places like Kern and Arrowhead, which are 4 years and definitely not academic. The previous poster went as far as to say Stanford isn't a 'true' academic BECAUSE it's not 4 years (even though it is).
 
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Yeah, my point is that '4 years means academic' isn't a great generalization in California. Not only for those UCs, but places like Kern and Arrowhead, which are 4 years and definitely not academic. The previous poster went as far as to say Stanford isn't a 'true' academic BECAUSE it's not 4 years (even though it is).

Bruh, when I think of 4 year academic, I don't think of Kern or Arrowhead - I don't think anybody does. I think of UCSF-SFGH, Stanford, UCLA RR/OV, UCSD, Yale, Northwestern, MGH/BWH, NYP, Sinai, etc. Most 3 year programs don't have the research infrastructure/output, elective time, financial resources, or multidisciplinary ties (industry partnerships, engineering/business schools, etc.) that all of these 4 year programs I listed enjoy. 4 year means academic was never my argument -- I agree with you, Stanford was very academic as a 3 year program, now moreso as a 4 year program.
 
Bruh, when I think of 4 year academic, I don't think of Kern or Arrowhead - I don't think anybody does.

Obviously....

Let's be honest--4 year programs are generally a lot more academic... (allow more time for longitudinal work).

This is why I used those examples, since it's a bad generalization in this case.

I'm also not sure how UCSF/Stanford/UCLA are more academic than Vandy/Pitt/UChicago because of their elective time. They certainly have access to everything else you mentioned. Plus their grads have an entire year after graduation for fellowship/research. I also interviewed at plenty of 3 and 4 year academic programs, and 3 years certainly don't seem to see their grads as disadvantaged.

I mean, Stanford was academic but is now 'moreso' simply by having a fourth year?
 
Obviously....



This is why I used those examples, since it's a bad generalization in this case.

I'm also not sure how UCSF/Stanford/UCLA are more academic than Vandy/Pitt/UChicago because of their elective time. They certainly have access to everything else you mentioned. Plus their grads have an entire year after graduation for fellowship/research. I also interviewed at plenty of 3 and 4 year academic programs, and 3 years certainly don't seem to see their grads as disadvantaged.

I mean, Stanford was academic but is now 'moreso' simply by having a fourth year?

Bruh, why so defensive? If it was so obvious, you wouldn't have had to Kern or Arrowhead as examples in the first place.

Vandy & Pitt don't have the level of access to industry partnerships and top tier graduate schools that UCSF/Stanford/UCLA enjoy. Part of this is geography, not inherent to 3 vs 4 year, but regardless, I disagree with you there. I agree, UofC is definitely a gem. Graduates from 4 year programs also pursue fellowships and generally have a higher chance of being recruited to faculty without a fellowship than 3 year graduates without fellowships.

After talking to residents/faculty from 3 vs 4 year programs THIS interview cycle, I got the sense that 4 year residents had more time to do more things over the course of 4 years -- this is super obvious, right? You have a higher chance of publishing more, getting exposed to more things, expanding your professional network, being more involved in national conferences/organizations/leadership, policy work, administration, business, etc. over the course of 4 years than 3 years. I think it's a good thing that future EM docs are trying to broaden their portfolio and grow the field. And that's also how I define a good academic program: I don't just measure the output of the faculty, but also the output of the residents. Stanford residents will enjoy a lot more elective time in a 4 year program --> most likely increased academic output from the residents.

Some people think 4 year programs are a financial mistake -- VALID POINT. Others think its a great longterm investment to do something you're passionate about that is relevant to EM and helps minimize the risk of burnout from being a full-time pit doc (we have the highest burnout rate BTW) -- ALSO VALID POINT.

I know myself. If I become a full-time pit doc, I'll get bored and I'll burn out after a decade. I want to both find and develop a second marketable skillset that helps grow the field, helps me get coin, stay happy, stay intellectually challenged, and mitigate circadian rhythm problems by working less shifts per month. After a lot of reflection, I determined the best way I could find that for me was through a 4 year program. Thankfully, I have a lot of role models who have done just this and are still very happy over a decade in.

If you see yourself deriving maximal happiness as a fulltime EM clinician in the community, more power to you -- go 3 years and never look back.
 
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Some people think 4 year programs are a financial mistake -- VALID POINT. Others think its a great longterm investment to do something you're passionate about that is relevant to EM and helps minimize the risk of burnout from being a full-time pit doc (we have the highest burnout rate BTW) -- ALSO VALID POINT.

I know myself. If I become a full-time pit doc, I'll get bored and I'll burn out after a decade. I want to both find and develop a second marketable skillset that helps grow the field, helps me get coin, stay happy, stay intellectually challenged, and mitigate circadian rhythm problems by working less shifts per month. After a lot of reflection, I determined the best way I could find that for me was through a 4 year program. Thankfully, I have a lot of role models who have done just this and are still very happy over a decade in.

If you see yourself deriving maximal happiness as a fulltime EM clinician in the community, more power to you -- go 3 years and never look back.

I mean, if you know you need an extra year to figure out what you want your niche to be, then power to you. The flip side of that is that if you figure out early on you want to do tox or US or policy or whatever, you're still spending that extra year there. But there are tons of 3 year grads that that go into fellowship and then do plenty to 'help grow the field'. I did an away this year at a 4 year 'powerhouse' California program, and they had no shortage of fellowship faculty/directors who were 3 year grads.
 
Most 3 year programs
This isn't about "most 3 year programs, this is about academic 3-year programs
don't have the research infrastructure/output,
Not true.
elective time,
True, but resident elective time doesn't make a program academic or not.
financial resources,
Not true.
or multidisciplinary ties (industry partnerships, engineering/business schools, etc.)
Also not true

that all of these 4 year programs I listed enjoy. 4 year means academic was never my argument -- I agree with you, Stanford was very academic as a 3 year program, now moreso as a 4 year program.
Literally the only thing they've changed is add more elective time for their residents -- that's not what makes a program academic or not.

You have a weird idea of what "academic" means. An academic residency is about the culture of the place: one in which the faculty is encouraged and supported in doing research, the faculty is on the leading edge of literature, there is usually a medical school affiliation so there is teaching going on at multiple levels. An academic residency is the type of place that will encourage residents to be life-long learners at the least, but ideally leaders in the field. The number of elective blocks that students have during residency is so far down in contributing to this culture that it is essentially irrelevant.
 
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As a research-heavy applicant this year, Vandy struck me as EXTREMELY academic and research-oriented, on par with any of the 4-years you mentioned, but only if the residents were interested in that, which most were not.


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I mean, if you know you need an extra year to figure out what you want your niche to be, then power to you. The flip side of that is that if you figure out early on you want to do tox or US or policy or whatever, you're still spending that extra year there. But there are tons of 3 year grads that that go into fellowship and then do plenty to 'help grow the field'. I did an away this year at a 4 year 'powerhouse' California program, and they had no shortage of fellowship faculty/directors who were 3 year grads.

If you already know what you want in life, I salute you. I wish I did. I matched into a legendary 4 year program and am very very happy. I hope you matched into the 3 year program of your dreams and are also very very happy.
 
This isn't about "most 3 year programs, this is about academic 3-year programs

Not true.

True, but resident elective time doesn't make a program academic or not.

Not true.

Also not true


Literally the only thing they've changed is add more elective time for their residents -- that's not what makes a program academic or not.

You have a weird idea of what "academic" means. An academic residency is about the culture of the place: one in which the faculty is encouraged and supported in doing research, the faculty is on the leading edge of literature, there is usually a medical school affiliation so there is teaching going on at multiple levels. An academic residency is the type of place that will encourage residents to be life-long learners at the least, but ideally leaders in the field. The number of elective blocks that students have during residency is so far down in contributing to this culture that it is essentially irrelevant.

We can agree to disagree re: resources and connections. What I'm looking for is probably very differerent from what you are outside of clinical training. Your definition of academic is more broad and all encompassing--I was definitely focusing on a narrow aspect of it. This is obviously a touchy topic. At the end of the day, if there were no value/minimal value added to a 4th year outside of geography/family, a lot less top tier applicants would be ranking academic 4 year programs so highly.

But then again, maybe I'm just another sucker for dat 4 year kool-aid.
 
I'm a new attending and UCSF/SFGH grad now working a community job in CA. I did get an interesting perspective on the post graduation hiring process that you might find helpful.

1) Going to any quality program (pretty much all on your list) will get you a community medicine job or a per diem job at an academic center in CA if they are hiring. If they are full and not hiring it won't matter where you did your training or how good of an applicant you are, you'll have to wait a year or two to get in. In the community you could go to USC, Harvard or podunk training program NOS and they will hire you if you can move the meat and keep your patient satisfaction scores up. Academic centers tend to have a number of open poorly paying per diem shifts that aren't all that difficult to get but easier to roll into if you graduate from their program.

2) If you want a tenured faculty position at an academic center there is a big push towards fellowship training. That means it's less important (but not unimportant) where you did your residency training, and more helpful where you did fellowship. I also found our program hired a lot out of the in house fellowship graduates. There was no apparent preference for the 4 year program + fellowship grads vs 3 year program + fellowship. Consider saving a year of your life and doing the 3+1 model if you want to go into academics, or just forget about the financial aspects since you are going into academics anyway and do what you want. The alternative pathway I saw towards academics is being in per diem purgatory for 1-3 years and having a 50/50 shot of being promoted into a regular teaching role if the residents and other faculty like you. Academic benefits have been eroding for health coverage and pension (CALPERS increasingly on the rocks and underfunded with mandatory contributions going up in this low interest rate environment) so think carefully about academic EM benefits vs compensation as it isn't what it used to be. There are some older faculty in really plush positions but I don't think that's realistic for new hires. There were 2-3 pension cuts for new hire faculty just in the 4 years I was in training though I didn't keep up with the specifics.

3) I like the idea of a mix of county and academic training. You'll get the sick patients but also the organ transplants and other tertiary referral stuff that you won't get as much of as a pure county hospital. Trauma isn't that hard, and the complex coding medical patients are what I find most difficult (ie the septic pulmonary HTN patient on flolan). On the other hand, many county hospitals are also receiving referral centers for community hospitals (my community job sends airlift patients to USC a lot due to an insurance arrangement with one of our local payers, plus UCLA, Stanford and less commonly UCSF).

4) Consider pediatric trauma and sick patients. Many people will say that the sick child is the hardest case and what makes an adult EM doc most uncomfortable. At many academic centers they have lots of sick kids BUT they get scooped up immediately by the PICU resident and you get less experience. Our little community hospital has a small group of CP epilepsy kids with persistent status epilepticus, peds intubations, post intubation sedation with vent management and vasopressors for 2-4 hours until the helicopter arrives etc which has been hard for me to adjust to after my academic training where PICU resources were 5 min away. Some of my colleagues, such as one who did training at Kern County had a ton more residency experience with this than I did.

5) Consider moonlighting. Not all residencies have the time or availability for moonlighting. It makes residency easier from a financial standpoint but also gets some needed exposure to community medicine. I feel like this was a week point for most residencies I looked at but can be easily overcome by finding what you need (ie urgent care, a local community level 2 trauma center etc) and doing some moonlighting. Of note, the Level 2 trauma center I worked at only took 4th year residents, so could be hard to do this in a 3 year program.

Good luck!
 
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I'm a new attending and UCSF/SFGH grad now working a community job in CA. I did get an interesting perspective on the post graduation hiring process that you might find helpful.

1) Going to any quality program (pretty much all on your list) will get you a community medicine job or a per diem job at an academic center in CA if they are hiring. If they are full and not hiring it won't matter where you did your training or how good of an applicant you are, you'll have to wait a year or two to get in. In the community you could go to USC, Harvard or podunk training program NOS and they will hire you if you can move the meat and keep your patient satisfaction scores up. Academic centers tend to have a number of open poorly paying per diem shifts that aren't all that difficult to get but easier to roll into if you graduate from their program.

2) If you want a tenured faculty position at an academic center there is a big push towards fellowship training. That means it's less important (but not unimportant) where you did your residency training, and more helpful where you did fellowship. I also found our program hired a lot out of the in house fellowship graduates. There was no apparent preference for the 4 year program + fellowship grads vs 3 year program + fellowship. Consider saving a year of your life and doing the 3+1 model if you want to go into academics, or just forget about the financial aspects since you are going into academics anyway and do what you want. The alternative pathway I saw towards academics is being in per diem purgatory for 1-3 years and having a 50/50 shot of being promoted into a regular teaching role if the residents and other faculty like you. Academic benefits have been eroding for health coverage and pension (CALPERS increasingly on the rocks and underfunded with mandatory contributions going up in this low interest rate environment) so think carefully about academic EM benefits vs compensation as it isn't what it used to be. There are some older faculty in really plush positions but I don't think that's realistic for new hires. There were 2-3 pension cuts for new hire faculty just in the 4 years I was in training though I didn't keep up with the specifics.

3) I like the idea of a mix of county and academic training. You'll get the sick patients but also the organ transplants and other tertiary referral stuff that you won't get as much of as a pure county hospital. Trauma isn't that hard, and the complex coding medical patients are what I find most difficult (ie the septic pulmonary HTN patient on flolan). On the other hand, many county hospitals are also receiving referral centers for community hospitals (my community job sends airlift patients to USC a lot due to an insurance arrangement with one of our local payers, plus UCLA, Stanford and less commonly UCSF).

4) Consider pediatric trauma and sick patients. Many people will say that the sick child is the hardest case and what makes an adult EM doc most uncomfortable. At many academic centers they have lots of sick kids BUT they get scooped up immediately by the PICU resident and you get less experience. Our little community hospital has a small group of CP epilepsy kids with persistent status epilepticus, peds intubations, post intubation sedation with vent management and vasopressors for 2-4 hours until the helicopter arrives etc which has been hard for me to adjust to after my academic training where PICU resources were 5 min away. Some of my colleagues, such as one who did training at Kern County had a ton more residency experience with this than I did.

5) Consider moonlighting. Not all residencies have the time or availability for moonlighting. It makes residency easier from a financial standpoint but also gets some needed exposure to community medicine. I feel like this was a week point for most residencies I looked at but can be easily overcome by finding what you need (ie urgent care, a local community level 2 trauma center etc) and doing some moonlighting. Of note, the Level 2 trauma center I worked at only took 4th year residents, so could be hard to do this in a 3 year program.

Good luck!

Hey bro, WHERE THE **** WERE YOU THE DAY BEFORE RANKLISTS WERE DUE?

S'all good though. I still got my "4-years iz da bestest" kool-aid, tears of sorrow, daddy's hedge fund, and Dr. Rosen's FOUR YEARS ARE OPTIMAL op-piece to help me sleep at night...

https://www.saem.org/docs/default-source/saem-documents/students/3vs4yearresidency.pdf?sfvrsn=4

#noragrets
 
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What about the three year UCs? UC Irvine and Davis seem to be pretty academic, especially US at Irvine and Peds EM at Davis with PECARN.

Both great programs. Both great a lot of respect in EM. The three year issue is a real issue, though, but their fellowship-trained grads are great.
 
I think this is a larger issue than most realize. Some of these county programs like Jacobi, Lincoln, UNM, and SUNY Downstate just NEVER rotate at an ED where customer service matters, and their attendings have no clue because they have lived their whole lives within such a system. If you are going county, I would advise looking at a program like Hennepin that rotate residents through a private hospital. Anyone can learn medicine. It's learning to work in a tough customer service environment that's the challenge. Most of those grads from places like Downstate go into academia/work at county forever. If that's your game, great, but know it before you enter.

that is precisely right. county seems exciting as a med student, when you want a job, a lot of what you learn in those programs isn't applicable/helpful.
 
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We can agree to disagree re: resources and connections. What I'm looking for is probably very differerent from what you are outside of clinical training. Your definition of academic is more broad and all encompassing--I was definitely focusing on a narrow aspect of it. This is obviously a touchy topic. At the end of the day, if there were no value/minimal value added to a 4th year outside of geography/family, a lot less top tier applicants would be ranking academic 4 year programs so highly.

But then again, maybe I'm just another sucker for dat 4 year kool-aid.
Location and prestige is the majority of why people pick these programs. They just try and come up with other reasons to justify it in their mind that don’t sound as superficial.
 
Both great programs. Both great a lot of respect in EM. The three year issue is a real issue, though, but their fellowship-trained grads are great.

An “issue” by what criteria? I can’t speak for UCI, but when I interviewed at Davis they provided procedure averages for their grads, which far surpassed requirements. Similarly, their population seemed to produce tons of critically ill patients and trauma activations. Compared to what I heard about the populations while interviewing at UCSF and UCSD (both listed as elite 4 years in this thread), their grads seem to have much better exposure to sick patients. The 4 years certainly get more exposure to quaternary care patients through UCSF and La Jolla, but on my away I didn’t really seem to see much ownership of those patients in the ED. Just curious as to what skill sets you notice 3 year grads lacking in.
 
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Location and prestige is the majority of why people pick these programs. They just try and come up with other reasons to justify it in their mind that don’t sound as superficial.

Are you calling Dr. Rosen...a liar?

And are you calling us SLOE slaying AOA candidates who matched into prestigious 4 year programs in great locales geographic prestige ******?

Dem fighting words.
 
Are you calling Dr. Rosen...a liar?

And are you calling us SLOE slaying AOA candidates who matched into prestigious 4 year programs in great locales geographic prestige ******?

Dem fighting words.
I mean yes and yes. Not saying its 100% uniform across the pool but there is a reason UCSD gets way better applicants than Fresno.
 
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An “issue” by what criteria? I can’t speak for UCI, but when I interviewed at Davis they provided procedure averages for their grads, which far surpassed requirements. Similarly, their population seemed to produce tons of critically ill patients and trauma activations. Compared to what I heard about the populations while interviewing at UCSF and UCSD (both listed as elite 4 years in this thread), their grads seem to have much better exposure to sick patients. The 4 years certainly get more exposure to quaternary care patients through UCSF and La Jolla, but on my away I didn’t really seem to see much ownership of those patients in the ED. Just curious as to what skill sets you notice 3 year grads lacking in.

I call BS. Every buddy of mine who rotated at UCSF and UCSD said the residents were rockstars and just as good as the ones at my home institution, which is an OG in EM. The UCI residents I spoke to said lack of quaternary care and lack of ortho were weaknesses in their program, so I call double BS on your "their grads seem to have much better exposure to sick patients". Unlike you, at least the UCI residents were more honest and balanced about how they viewed their program. That being said, UCI is an awesome program in a beautiful part of the country.
 
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I call BS. Every buddy of mine who rotated at UCSF and UCSD said the residents were rockstars and just as good as the ones at my home institution, which is an OG in EM. The UCI residents I spoke to said lack of quaternary care and lack of ortho were big weaknesses in their program, so I call double BS on your "their grads seem to have much better exposure to sick patients". Unlike you, at least the UCI residents were more honest and balanced about how they viewed their program. That being said, UCI is an awesome program in a beautiful part of the country.

I was talking about UC Davis, as that's where I interviewed.. hence me saying I can't speak to UCI. I'm not disparaging either of those programs, I don't think anyone would say that UCSF or UCSD turn out anything other than well trained residents. I also rotated at one of those sites and can attest to that. I'm saying that both those schools are in areas with relatively healthy populations. Lots of 'worried well', and lots of homelessness. UC Davis has a huge catchment area and sees lots of sick people from around the central valley, meaning lots of poor rural areas, migrant workers, several major highways going through, ect.. Actually very close to the UCSF-Fresno population, which is one of their main selling points. I realize that you chose to go the 'legendary' 4 year route so you're defensive on this topic, but at least look at what I actually said before going off about honesty and balance haha.
 
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I was talking about UC Davis, as that's where I interviewed.. hence me saying I can't speak to UCI. I'm not disparaging either of those programs, I don't think anyone would say that UCSF or UCSD turn out anything other than well trained residents. I also rotated at one of those sites and can attest to that. I'm saying that both those schools are in areas with relatively healthy populations. Lots of 'worried well', and lots of homelessness. UC Davis has a huge catchment area and sees lots of sick people from around the central valley, meaning lots of poor rural areas, migrant workers, several major highways going through, ect.. Actually very close to the UCSF-Fresno population, which is one of their main selling points. I realize that you chose to go the 'legendary' 4 year route so you're defensive on this topic, but at least look at what I actually said before going off about honesty and balance haha.

Touche. One of my close friends who's ahead of us graduated from UC Davis. This person rotated at UCSF-SFGH and ranked it higher than his/her own home program. He/she raved about the clinical caliber of the residents and attendings and the more balanced quaternary/county experiences. I also interviewed at UC Davis. I still call BS on your statement "their grads seem to have much better exposure to sick patients". UCD is probably the best 3 year program in California.

I'll be honest. I have no regrets ranking certain 4 year programs so highly, but that's also because what I want from my EM career is so different from most people (even if I'm not 100% what I want to do--more like 70% sure). There's only a handful of institutions that even offer what I want to do, and the ones that do it best (by a long shot) are all 4 year programs. Because of this, my perspective on what's best is admittedly very skewed to my own interest, which I bet 99% of you don't share.

So yeah, I'm in the small minority. I bet, at the end of the day, prestige and geography make up a large part of most peoples' rank lists, as painful as that is to say. Prestige and geography are not as applicable to me because my choices were so limited early on, but I don't mind making fun of myself, which I do all the time, including in this thread.
 
I mean yes and yes. Not saying its 100% uniform across the pool but there is a reason UCSD gets way better applicants than Fresno.
Best response ever. So you're calling BS on Dr. Rosen's FOUR YEARS ARE OPTIMAL op-piece?
 
He's saying Rosen has his own opinion which is not fact.
Kind of like how Rosens testimonies weren't always based on fact.
He isn't a great choice to prove your argument. The book has ethos, he does not... again, given the whole lying for cash thing.

Perhaps this was before your time as a ms1-ms2.
 
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He's saying Rosen has his own opinion which is not fact.
Kind of like how Rosens testimonies weren't always based on fact.
He isn't a great choice to prove your argument. The book has ethos, he does not... again, given the whole lying for cash thing.

Perhaps this was before your time as a ms1-ms2.

Sorry, my text doesn't capture the fact that I was being playful (not serious at all). I just liked how he responded. I was being facetious about quoting Rosen. However, I did not know about any cash thing--makes me sad to hear. Could you elaborate?
 
Best response ever. So you're calling BS on Dr. Rosen's FOUR YEARS ARE OPTIMAL op-piece?
Yes. Fourth year re$ident$ exi$t for one purpo$e.
 
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