Specific guidance re: OHSU?

[clausewitz2]

I am hoping that by being very specific about my goal, I will bring people familiar with OHSU out of the woodwork, but this is a case of the more general question: "how do I position myself to maximize my chance of matching at a very particular program?"

In this case, it is OHSU. Portland is one of my favorite places on earth, my wife feels similarly, their program fits my interests in so many ways it is a little scary, especially the opportunities for cross-cultural community mental health and somatization disorders.

My relevant info: currently a third year, expecting to graduate from a middle-of-the-pack US medical school. Step 1 score within a couple points of national median for last year. Will have Step 2 done by end of summer. My school doesn't officially assign honors, but clerkship-wise, above 90% in everything but ob/gyn so far (and that was high 80s). Have a good LOR from a family medicine preceptor working in a refugee health clinic, strong letter from the neurology PD, working on a letter from psych. Will be doing a psych and neuro AI at the moment, in the summer months.

I have a PhD in linguistics that focused on neuroimaging of speech disorders, the kind of topic that seems to make neurologists ask many follow-up questions and makes psychiatrists smile politely. I spent six months designing a curriculum for, setting up, and running a K-8 English program at a government school in rural Cambodia, so my cross-cultural experience is non-zero. Also have family in the Portland area, so personal connection.

So obviously I need to apply and rank OHSU highly, and try and convey my very genuine enthusiasm. What else should I be doing? Do you collectively think an audition rotation would be helpful? I may be in Portland in a few months for unrelated reasons - in non-medical academia this would be a perfect opportunity to drop by the lab of someone I was interested in working with and make introductions, but I have a poor sense of whether this fits with How Things Are Done in medicine. Are there particular electives or a different choice of AI that would better position me for this particular program?
I appreciate that the ultimate answer might be "not a lot more you can do", but if I don't manage to match there I would like to feel like I had done everything I could.

---

Members don't see this ad.

 

[slappy]

You have a good step 1 score. I think you're already well-poised to matching at OHSU. Considering the program is not overly competitive (they didn't fill multiple spots last year), I would caution against doing an away rotation. You have a higher chance of rubbing someone the wrong way the longer you spend at the program. And you really want to match in Portland to be with family. On the flip side however, an away rotation can give you an idea of what to expect at the program once you're a resident, so if there is any way you would consider living anywhere else except Portland, go for it as the benefits would then balance the risks.

 

[notdeadyet]

In your case, if you're so fixated on OHSU, if you can do a 4th year elective, I'd do it and do it early (before February). If you have the flexibility, doing it early enough that you can get an OHSU letter in your app packet would be great.

This all assumes you're willing to work smart and hard and that you make a good impression. If folks have told you that you are awkward or rub people wrong, you might skip the away as it has the potential to do more harm than good.

But this is advice for pretty much any program. We have at least one poster who does residency there who might be able to chime in with specifics. Incidentally, I really liked OHSU and Portland too and ranked them highly.

 

[Opira]

It's unfortunate that you need to be in Portland. I interviewed at OHSU last year and ranked it dead last. There was a lot of discussion about the current state of affairs at OHSU last year here and here. Can you live in Seattle and commute to Portland once in a while? UW-Seattle is a much better program and you definitely have a shot there.

 

[clausewitz2]

It's unfortunate that you need to be in Portland. I interviewed at OHSU last year and ranked it dead last. There was a lot of discussion about the current state of affairs at OHSU last year here and here. Can you live in Seattle and commute to Portland once in a while? UW-Seattle is a much better program and you definitely have a shot there.

I appreciate the feedback and the links. Reading them, I can understand sort of why it might not be the most desirable choice for everyone, but would you mind sharing why you ranked it dead last? A lot of the criticism seems to surround the work load, which even if heavy for psych I guess seems not so bad to me as I was until very recently seriously considering neuro and contemplating the horrors of holding the stroke pager.

 

[Opira]

I appreciate the feedback and the links. Reading them, I can understand sort of why it might not be the most desirable choice for everyone, but would you mind sharing why you ranked it dead last? A lot of the criticism seems to surround the work load, which even if heavy for psych I guess seems not so bad to me as I was until very recently seriously considering neuro and contemplating the horrors of holding the stroke pager.

Sure. Here are some of the negatives I'd compiled after my interview at OHSU last year (that included an additional day and didactics), and from talking with others including current residents at the program.

- single adult inpatient unit, located in a basement; not a nice facility
- no inpatient child and adolescent units at all
- highly service-oriented and resident-dependent; more than most
- tying into above is a very fixed program structure that allows little time for electives until late fourth year
- little time and opportunities for research
- way too much focus on rural and community psychiatry
- middling didactics that does not compensate for the above
- a very apathetic and unenthusiastic program director
- residents have been fired from the program in the recent past
- heavy call schedule, intense calls, and heavy workload, as you'd covered above
- heavily front-loaded overall but you still take calls until third year, AND you take backup and jeopardy calls in fourth year

 

[clausewitz2]

Edit: double post

 

[Doctor Bagel]

Hey there, as probably everyone here knows, I'm a recent grad at OHSU. About your original question, aways can be good to give perspective on a program, but it's not necessary. If you love Portland, though, why not? More importantly for matching, I'd just make sure the program knows that you're really interested in them. This is probably true anywhere.

About OHSU, I think some of the information shared in reviews last year was off. Like all places, OHSU has strengths and weaknesses. Regarding Opira's specific points, here are my thoughts --

- single adult inpatient unit, located in a basement; not a nice facility -- true, it's not a nice facility. Attendings and training there is pretty good, though. More importantly, there's a plan in the works to close it and open a new free-standing psychiatric hospital, which hopefully will be open in ~18 months. You also get to rotate at the VA, which is a beautiful unit, although I prefer OHSU, and the state hospital.
- no inpatient child and adolescent units at all -- true, all child experience is outpatient. I'm not sure about options to set up an elective inpatient rotation. Might be worth asking about.
- highly service-oriented and resident-dependent; more than most -- it's definitely not a resident independent type of program. Hard to compare with other programs.
- tying into above is a very fixed program structure that allows little time for electives until late fourth year -- there's some talk about allowing more electives early on. As it is right now, it's true that there are no electives in the first and second year. Third year, you do six months of community, and you get to pick your community rotation. 4th year is very open and almost all electives. You do get to start your outpatient clinic second year.
- little time and opportunities for research -- there's a research track now, which I think is directed at this. Again, 4th year is very open, but yeah, there's no dedicated research time before PGY3 year at the earlier for most residents.
- way too much focus on rural and community psychiatry -- ??, we don't have much focus on rural psychiatry, so I'm puzzled as to where this comes from. Community psychiatry is a strong historical focus of the program. Most grads probably don't do community psychiatry, though. We also get lots of exposure to other things like the VA, and OHSU has a relationship with the psychoanalytic center.
- middling didactics that does not compensate for the above -- some good, some bad. Only 1/2 day. Child didactics are great. Some psychotherapy didactics are good (psychoanalytic stuff), some not so great (CBT). Psychopharm could probably be better. OHSU historically is more a place where you learn on the job, versus in lectures. Things are always changing, though.
- a very apathetic and unenthusiastic program director -- that wouldn't be my characterization. The PD is a genuinely well-intentioned and nice person.
- residents have been fired from the program in the recent past -- this is becoming more distant history, and there are long stories here. The program now is very dedicated to having residents complete their training at OHSU. The current PGY1 to 3 classes are entirely intact.
- heavy call schedule, intense calls, and heavy workload, as you'd covered above -- call schedule is not light, but it's nowhere near the heaviest from what I've heard. Calls are actually not particularly intense. I probably slept some every night I was on call. I can't think of a single call where I was going the whole time (assuming 24 hour calls, not 3 hour short calls, which yes, can be intense due to the short time frame).
- heavily front-loaded overall but you still take calls until third year, AND you take backup and jeopardy calls in fourth year -- my confusion here is that I imagine most programs have a backup and jeapordy system serviced by upper level residents. I'm not sure how you could have a call system without it. I think OHSU being upfront about the system was their downfall here. Third year call is very light (like one shift in a six week block). System is still front-loaded, which fits with resident preferences.

Oh yeah, regarding the match last year -- there was only one unfilled spot, as far as I know.

 

[Opira]

Hey there, as probably everyone here knows, I'm a recent grad at OHSU. About your original question, aways can be good to give perspective on a program, but it's not necessary. If you love Portland, though, why not? More importantly for matching, I'd just make sure the program knows that you're really interested in them. This is probably true anywhere.

About OHSU, I think some of the information shared in reviews last year was off. Like all places, OHSU has strengths and weaknesses. Regarding Opira's specific points, here are my thoughts --

- single adult inpatient unit, located in a basement; not a nice facility -- true, it's not a nice facility. Attendings and training there is pretty good, though. More importantly, there's a plan in the works to close it and open a new free-standing psychiatric hospital, which hopefully will be open in ~18 months. You also get to rotate at the VA, which is a beautiful unit, although I prefer OHSU, and the state hospital.
- no inpatient child and adolescent units at all -- true, all child experience is outpatient. I'm not sure about options to set up an elective inpatient rotation. Might be worth asking about.
- highly service-oriented and resident-dependent; more than most -- it's definitely not a resident independent type of program. Hard to compare with other programs.
- tying into above is a very fixed program structure that allows little time for electives until late fourth year -- there's some talk about allowing more electives early on. As it is right now, it's true that there are no electives in the first and second year. Third year, you do six months of community, and you get to pick your community rotation. 4th year is very open and almost all electives. You do get to start your outpatient clinic second year.
- little time and opportunities for research -- there's a research track now, which I think is directed at this. Again, 4th year is very open, but yeah, there's no dedicated research time before PGY3 year at the earlier for most residents.
- way too much focus on rural and community psychiatry -- ??, we don't have much focus on rural psychiatry, so I'm puzzled as to where this comes from. Community psychiatry is a strong historical focus of the program. Most grads probably don't do community psychiatry, though. We also get lots of exposure to other things like the VA, and OHSU has a relationship with the psychoanalytic center.
- middling didactics that does not compensate for the above -- some good, some bad. Only 1/2 day. Child didactics are great. Some psychotherapy didactics are good (psychoanalytic stuff), some not so great (CBT). Psychopharm could probably be better. OHSU historically is more a place where you learn on the job, versus in lectures. Things are always changing, though.
- a very apathetic and unenthusiastic program director -- that wouldn't be my characterization. The PD is a genuinely well-intentioned and nice person.
- residents have been fired from the program in the recent past -- this is becoming more distant history, and there are long stories here. The program now is very dedicated to having residents complete their training at OHSU. The current PGY1 to 3 classes are entirely intact.
- heavy call schedule, intense calls, and heavy workload, as you'd covered above -- call schedule is not light, but it's nowhere near the heaviest from what I've heard. Calls are actually not particularly intense. I probably slept some every night I was on call. I can't think of a single call where I was going the whole time (assuming 24 hour calls, not 3 hour short calls, which yes, can be intense due to the short time frame).
- heavily front-loaded overall but you still take calls until third year, AND you take backup and jeopardy calls in fourth year -- my confusion here is that I imagine most programs have a backup and jeapordy system serviced by upper level residents. I'm not sure how you could have a call system without it. I think OHSU being upfront about the system was their downfall here. Third year call is very light (like one shift in a six week block). System is still front-loaded, which fits with resident preferences.

Thank you for your counterpoint. I still think there are a lot better programs in the nearby states - UW-Seattle definitely comes to mind. I'm sure you're an excellent psychiatrist still, so I don't intend any offense. I'm just posting my personal views on the program and why I ranked it so low.

About the backup and jeopardy calls, in most programs that are not resident dependent (like mine), the attendings cover for you when you don't show up for work. In other words, the resident is there to learn - not to ease the work of the attendings. So, if you get sick, the only one that gets inconvenienced is yourself. I'm not talking about ideals either - this is currently the case at my program, and at the programs my classmates from medical school had matched.

 

[Doctor Bagel]

Thank you for your counterpoint. I still think there are a lot better programs in the nearby states - UW-Seattle definitely comes to mind. I'm sure you're an excellent psychiatrist still, so I don't intend any offense. I'm just posting my personal views on the program and why I ranked it so low.

About the backup and jeopardy calls, in most programs that are not resident dependent (like mine), the attendings cover for you when you don't show up for work. In other words, the resident is there to learn - not to ease the work of the attendings. So, if you get sick, the only one that gets inconvenienced is yourself. I'm not talking about ideals either - this is currently the case at my program, and at the programs my classmates from medical school had matched.

The attendings cover call for when a resident is sick? I'm having trouble picturing attendings staying in house overnight, but if so, good for them.

UW-Seattle is possibly a more prestigious program. I don't know many details about it -- I interviewed there but ranked it lower on my list because I didn't click there (it felt too big and a little too serious for me). I'm comfortable with my choices and think that a reasonable person might pick OHSU over UW.

 

[Opira]

The attendings cover call for when a resident is sick? I'm having trouble picturing attendings staying in house overnight, but if so, good for them.

No one stays overnight. Psych ER is covered by attendings and residents in shifts, and inpatient attendings and residents take call on phone and come in only if need be.

 

[clausewitz2]

Hey there, as probably everyone here knows, I'm a recent grad at OHSU. About your original question, aways can be good to give perspective on a program, but it's not necessary. If you love Portland, though, why not? More importantly for matching, I'd just make sure the program knows that you're really interested in them. This is probably true anywhere.

About OHSU, I think some of the information shared in reviews last year was off. Like all places, OHSU has strengths and weaknesses. Regarding Opira's specific points, here are my thoughts --

- single adult inpatient unit, located in a basement; not a nice facility -- true, it's not a nice facility. Attendings and training there is pretty good, though. More importantly, there's a plan in the works to close it and open a new free-standing psychiatric hospital, which hopefully will be open in ~18 months. You also get to rotate at the VA, which is a beautiful unit, although I prefer OHSU, and the state hospital.
- no inpatient child and adolescent units at all -- true, all child experience is outpatient. I'm not sure about options to set up an elective inpatient rotation. Might be worth asking about.
- highly service-oriented and resident-dependent; more than most -- it's definitely not a resident independent type of program. Hard to compare with other programs.
- tying into above is a very fixed program structure that allows little time for electives until late fourth year -- there's some talk about allowing more electives early on. As it is right now, it's true that there are no electives in the first and second year. Third year, you do six months of community, and you get to pick your community rotation. 4th year is very open and almost all electives. You do get to start your outpatient clinic second year.
- little time and opportunities for research -- there's a research track now, which I think is directed at this. Again, 4th year is very open, but yeah, there's no dedicated research time before PGY3 year at the earlier for most residents.
- way too much focus on rural and community psychiatry -- ??, we don't have much focus on rural psychiatry, so I'm puzzled as to where this comes from. Community psychiatry is a strong historical focus of the program. Most grads probably don't do community psychiatry, though. We also get lots of exposure to other things like the VA, and OHSU has a relationship with the psychoanalytic center.
- middling didactics that does not compensate for the above -- some good, some bad. Only 1/2 day. Child didactics are great. Some psychotherapy didactics are good (psychoanalytic stuff), some not so great (CBT). Psychopharm could probably be better. OHSU historically is more a place where you learn on the job, versus in lectures. Things are always changing, though.
- a very apathetic and unenthusiastic program director -- that wouldn't be my characterization. The PD is a genuinely well-intentioned and nice person.
- residents have been fired from the program in the recent past -- this is becoming more distant history, and there are long stories here. The program now is very dedicated to having residents complete their training at OHSU. The current PGY1 to 3 classes are entirely intact.
- heavy call schedule, intense calls, and heavy workload, as you'd covered above -- call schedule is not light, but it's nowhere near the heaviest from what I've heard. Calls are actually not particularly intense. I probably slept some every night I was on call. I can't think of a single call where I was going the whole time (assuming 24 hour calls, not 3 hour short calls, which yes, can be intense due to the short time frame).
- heavily front-loaded overall but you still take calls until third year, AND you take backup and jeopardy calls in fourth year -- my confusion here is that I imagine most programs have a backup and jeapordy system serviced by upper level residents. I'm not sure how you could have a call system without it. I think OHSU being upfront about the system was their downfall here. Third year call is very light (like one shift in a six week block). System is still front-loaded, which fits with resident preferences.

Oh yeah, regarding the match last year -- there was only one unfilled spot, as far as I know.

The major reason why not for me has been that my wife's employment (also in mental health) would not really allow her to take off a month and come with me, and if it would be neutral/negative to do an away I would prefer not to spend quite so long two thousand miles away. If it is a net positive, however, I am well up for it. Good to hear about the new facility coming on-line in the not-too-distant future. A focus on community psychiatry is a net positive for me.

I appreciate everyone's responses and the very useful information. A couple of other people connected to the program have reached out to me via PM with even more useful information, so I think I have a pretty good idea of what I ought to be doing going forward.

 

[Opira]

Good luck.

 

[splik]

op, with a phd in neuroscience related field you will have programs salivating over you and will have your top pick of programs unless you have the personality of a slug. there was a lot of ohsu bashing last year on this forum and im not sure it was entirely fair. if you are interested in community psychiatry and want to live in portland i'm not sure how you would go wrong. while i agree with opira that uw is a much more prestigious program and has a lot wider range of opportunities, it is also a different program. OHSU is definitely stronger in community psychiatry. and its the only program in portland so if that's where you wanna live then that's where you'd go for residency.

 

[Doctor Bagel]

No one stays overnight. Psych ER is covered by attendings and residents in shifts, and inpatient attendings and residents take call on phone and come in only if need be.

Ah, so you have 24 hour attending in house coverage in the ED anyway? That's nice. Of course I only trained at one place, but I'm guessing that's not entirely the norm aside from big programs or programs in NY, which I think maybe requires that. From reading the call versus night float discussion on here, it sounds like residents being in house alone is more the norm in a lot of the psychiatry world for good or for bad.

Hey, maybe with our new awesome hospital we'll get that. We're supposed to get a dedicated psych ED, something Portland does not have, and that might be coupled with inhouse attendings all the time.

 

[MLT2MT2DO]

Sure. Here are some of the negatives I'd compiled after my interview at OHSU last year (that included an additional day and didactics), and from talking with others including current residents at the program.

- a very apathetic and unenthusiastic program director

I'm sorry, this is just flat out incorrect. Maybe he was ill during your interview or had other things going on. Dr. Kinzie is a great guy who is not only enthusiastic but very personable.

You can state negatives about anybody, including him, but the two adjectives you picked would be about the last two adjectives, from Webster's, I would have used.

 

[heyjack70]

I'm sorry, this is just flat out incorrect. Maybe he was ill during your interview or had other things going on. Dr. Kinzie is a great guy who is not only enthusiastic but very personable.

You can state negatives about anybody, including him, but the two adjectives you picked would be about the last two adjectives, from Webster's, I would have used.

Agreed. I met Kinzie and he is an energetic dude.

 

[MLT2MT2DO]

I am hoping that by being very specific about my goal, I will bring people familiar with OHSU out of the woodwork, but this is a case of the more general question: "how do I position myself to maximize my chance of matching at a very particular program?"

In this case, it is OHSU. Portland is one of my favorite places on earth, my wife feels similarly, their program fits my interests in so many ways it is a little scary, especially the opportunities for cross-cultural community mental health and somatization disorders.

My relevant info: currently a third year, expecting to graduate from a middle-of-the-pack US medical school. Step 1 score within a couple points of national median for last year. Will have Step 2 done by end of summer. My school doesn't officially assign honors, but clerkship-wise, above 90% in everything but ob/gyn so far (and that was high 80s). Have a good LOR from a family medicine preceptor working in a refugee health clinic, strong letter from the neurology PD, working on a letter from psych. Will be doing a psych and neuro AI at the moment, in the summer months.

I have a PhD in linguistics that focused on neuroimaging of speech disorders, the kind of topic that seems to make neurologists ask many follow-up questions and makes psychiatrists smile politely. I spent six months designing a curriculum for, setting up, and running a K-8 English program at a government school in rural Cambodia, so my cross-cultural experience is non-zero. Also have family in the Portland area, so personal connection.

So obviously I need to apply and rank OHSU highly, and try and convey my very genuine enthusiasm. What else should I be doing? Do you collectively think an audition rotation would be helpful? I may be in Portland in a few months for unrelated reasons - in non-medical academia this would be a perfect opportunity to drop by the lab of someone I was interested in working with and make introductions, but I have a poor sense of whether this fits with How Things Are Done in medicine. Are there particular electives or a different choice of AI that would better position me for this particular program?
I appreciate that the ultimate answer might be "not a lot more you can do", but if I don't manage to match there I would like to feel like I had done everything I could.

I did an audition at OHSU a few months ago, I think if you are able to swing it you should do the same. I ended doing the Intercultural Psych, I would probably recommend this rotation in your case, especially with the Cambodian background you have (one of the clinics is the Cambodian clinic). This is mostly a shadowing rotation, but you are able to get to work close with many faculty one-on-one to include the PD, I was with Dr. Kinzie 2 half-days a week. You are also able to attend a few didactics.

I originally did an audition due to the fact OHSU appeared to be fairly random last year as to who they invited for interviews, regardless of the application, and I didn't want to be passed up. I believe that even if I don't end up at OHSU, that I still got a really unique learning experience out of this.

 

[notdeadyet]

About the backup and jeopardy calls, in most programs that are not resident dependent (like mine), the attendings cover for you when you don't show up for work. In other words, the resident is there to learn - not to ease the work of the attendings. So, if you get sick, the only one that gets inconvenienced is yourself. I'm not talking about ideals either - this is currently the case at my program, and at the programs my classmates from medical school had matched.

I always learn something by coming to SDN...

I'm not familiar with the term "resident dependent." But I do know that some programs are not "resident dependent." Some programs began as stand-along psychiatric services and programs in which residencies were later added and program operations could likely continue along without the presence of residents. Kaiser comes to mind. Kaweah Delta is another.

I'd argue that many-to-most programs are in fact "resident dependent." The departments were designed with residents in mind and often built around the residencies. Residents are integral to operations of the hospitals, clinics, and services. The downside to this arrangement is that as a resident you have a lot of responsibility and ownership to how things are run. The upside is the same thing. MGH would not work well without its residents. Nor would many of the major medical centers.

Whether its a plus or a minus is probably applicant-dependent, but I think ruling out programs that are "resident dependent" might be a bit limiting as you'll be closing doors to many of the very good ones. Most programs I know of have jeopardy and residents cover for each other. This isn't punitive, it's necessary. It's also how things tend to work after residency as well.

 

[notdeadyet]

I did an audition at OHSU a few months ago, I think if you are able to swing it you should do the same. I ended doing the Intercultural Psych, I would probably recommend this rotation in your case, especially with the Cambodian background you have (one of the clinics is the Cambodian clinic). This is mostly a shadowing rotation, but you are able to get to work close with many faculty one-on-one to include the PD, I was with Dr. Kinzie 2 half-days a week. You are also able to attend a few didactics.

That sounds like great exposure, and I was very interested in the Intercultural Psychiatry clinic. Getting facetime with the PD is never a bad thing if you're interested in a program.

OP- like others have said, you'd likely match without the away, but if you're really focused on one program and you can impress when you rotate, it's well worth considering. In part because every residency program likes firsthand familiarity. It's also handy because you will never learn a program as well as when you rotate there. Good luck and let us know how it all turns out...

 

[clausewitz2]

That sounds like great exposure, and I was very interested in the Intercultural Psychiatry clinic. Getting facetime with the PD is never a bad thing if you're interested in a program.

OP- like others have said, you'd likely match without the away, but if you're really focused on one program and you can impress when you rotate, it's well worth considering. In part because every residency program likes firsthand familiarity. It's also handy because you will never learn a program as well as when you rotate there. Good luck and let us know how it all turns out...

Thanks. I am fairly sold on doing an early away rotation (with any luck, in precisely that clinic) at this point. While I imagine I am someone who is rather boring at large parties, generally my evaluations have been quite positive and are liberally littered with adjectives like "well-liked", so I believe I can impress.

 

[Armadillos]

I'm not sure what the right term is, but I agree with the above that some programs have a "resident independent" feel in that residents are primarily there for education and not service.

Brown for example seemed this way. Yale seemed to lean that way as well (I think some services residents don't even have to write notes). Many programs cover weekend rounds with moonlighters/attending only coverage. My program is not this way at all, so there is definitely variation.

 

[notdeadyet]

I'm not sure what the right term is, but I agree with the above that some programs have a "resident independent" feel in that residents are primarily there for education and not service.

Brown for example seemed this way. Yale seemed to lean that way as well (I think some services residents don't even have to write notes). Many programs cover weekend rounds with moonlighters/attending only coverage. My program is not this way at all, so there is definitely variation.

Live and learn. I wonder how big a part endowment plays?

 

[slappy]

I'm sorry, this is just flat out incorrect. Maybe he was ill during your interview or had other things going on.

To be fair, a lot of the interview reviews paint him in a slightly negative light. Perhaps he just doesn't "interview" well?

I'm not sure what the right term is, but I agree with the above that some programs have a "resident independent" feel in that residents are primarily there for education and not service. Brown for example seemed this way. Yale seemed to lean that way as well (I think some services residents don't even have to write notes). Many programs cover weekend rounds with moonlighters/attending only coverage. My program is not this way at all, so there is definitely variation.

I agree with this. I've seen more "resident independent" than "resident dependent" programs. Maybe it's a coastal thing, I don't know. A question I asked residents at dinner during my interviews was how long the attendings took to decide to grant a two-week leave. If the answer was "instantaneous", I felt it was a good predictor of a "resident independent" program, among other things.

 

[notdeadyet]

A question I asked residents at dinner during my interviews was how long the attendings took to decide to grant a two-week leave. If the answer was "instantaneous", I felt it was a good predictor of a "resident independent" program, among other things.

Yeah, I think this dichotomy still eludes me. You'd get instantaneous approval at my place, but there are also policies that make that possible. If you're one of two residents on an inpatient team, for instance, you don't take vacation at the same time other than the holidays.

This has been interesting. I'll have to look into this more. I'm having trouble thinking how operationally residents can be non-essential to patient care and still get best-of-breed training. The comment about not writing notes at Yale makes me wonder how that works, as they obviously are an excellent program. If you aren't writing orders and notes, how are you not just shadowing (albeit with a louder voice)? And if you aren't functioning as a critical member of the care team at these programs, are you supposed to learn to become one post-residency?

I know folks who went to Yale. I'll have to see how they reconciled this.

 

[Armadillos]

Yeah, I think this dichotomy still eludes me. You'd get instantaneous approval at my place, but there are also policies that make that possible. If you're one of two residents on an inpatient team, for instance, you don't take vacation at the same time other than the holidays.

This has been interesting. I'll have to look into this more. I'm having trouble thinking how operationally residents can be non-essential to patient care and still get best-of-breed training. The comment about not writing notes at Yale makes me wonder how that works, as they obviously are an excellent program. If you aren't writing orders and notes, how are you not just shadowing (albeit with a louder voice)? And if you aren't functioning as a critical member of the care team at these programs, are you supposed to learn to become one post-residency?

I know folks who went to Yale. I'll have to see how they reconciled this.

I think at yale it's only a portion of the inpatient services where residents don't write notes, and it might be a recent change. I think it was a way to deal with fact that a certain unit frequently had no residents because they were post call or something. My understanding was residents still did all the orders and d/c summaries

My program is nightfloat heavy so the way it's scheduled there would never be a time a team was without residents unless 2 were sick or something on same day

 

[MacDonaldTriad]

The difference between “service needs over education” is merely a matter of useful supervision in my mind. If trainees are complaining about their work loads, it is often because the nature of the work isn’t educational and not the fact of there being work to do.
I think I have managed to accept much of the changes in medicine “millennials” have created. I’ll admit to some difficulty with piercings and tattoos, but what I seem unable to get my arms around is the concept of “resident dependent services”. Since when did this become a bad thing? I certainly don’t want anyone caring for me who is a product of training that was a “resident independent”. Doesn’t this describe the difference between medical school and graduate medical education?
Yes, I know how I sound, but I cannot use the “snow drifts were higher” analogy right now given the weather. So, it was uphill walking to school in both directions back in my day.

 

[heyjack70]

The difference between “service needs over education” is merely a matter of useful supervision in my mind. If trainees are complaining about their work loads, it is often because the nature of the work isn’t educational and not the fact of there being work to do.
I think I have managed to accept much of the changes in medicine “millennials” have created. I’ll admit to some difficulty with piercings and tattoos, but what I seem unable to get my arms around is the concept of “resident dependent services”. Since when did this become a bad thing? I certainly don’t want anyone caring for me who is a product of training that was a “resident independent”. Doesn’t this describe the difference between medical school and graduate medical education?
Yes, I know how I sound, but I cannot use the “snow drifts were higher” analogy right now given the weather. So, it was uphill walking to school in both directions back in my day.

I think the concern is if it's so resident dependent there is a lack of attending supervision because essentially the residents are doing everything and the attending is hardly there.

 

[MacDonaldTriad]

I think the concern is if it's so resident dependent there is a lack of attending supervision because essentially the residents are doing everything and the attending is hardly there.

Sure, but who is to judge the ideal amount? Clearly having attendings “hardly there” is too far in one direction, but if the ACGME asks a question about “resident dependent services”, I would bet that some of the programs with greater than average supervision will get more bad marks than some with less.

This kind of question is more dependent on resident expectation that on supervision quantity. If every resident got exactly the amount they felt was ideal, the amounts would be all over the board. Some resident need more than others, but it is also true that some residents who want more need some weaning, and some residents who don’t want more may need more.

 

[notdeadyet]

The difference between “service needs over education” is merely a matter of useful supervision in my mind. If trainees are complaining about their work loads, it is often because the nature of the work isn’t educational and not the fact of there being work to do.
I think I have managed to accept much of the changes in medicine “millennials” have created. I’ll admit to some difficulty with piercings and tattoos, but what I seem unable to get my arms around is the concept of “resident dependent services”. Since when did this become a bad thing? I certainly don’t want anyone caring for me who is a product of training that was a “resident independent”. Doesn’t this describe the difference between medical school and graduate medical education?

Yep. I feel like the "millennial issue" is kind of the 800# gorilla in medical education right now. It's tough, because we are obviously talking about generalizations and many folks of the generation won't fit with the description. But it's also hard to not see the gross differences between folks in their late 20's vs in their 30's or 40's. I noticed it in medical school and can see it in residency as well and I've yet to see someone in their 30's/40's also not see the difference.

The thing I struggle with most is the change of how "service" has become "service without sacrifice" or "service on my own terms." This is likely accentuated by the fact that folks going into medical school tend to come from socioeconomic classes where a sense of entitlement is more prevalent anyway. But it's still a bit hard to swallow sometimes when folks seem to want to wave the banner of public service but not want to bear the trappings of public servant. I also notice many folks often fight a lot harder over slights and perks as residents than they do over issues of medical care and patient wellness. The predominance of this also seems to be inversely proportional to age, which is interesting as creature comforts and the like is something I would more typically associate with us older farts.

Residencies are going to have to develop a better way to market what residency actually is to millennial folks. I notice the disconnect is often thinking that residency is somehow an extension of medical school (which is in part the fault of medical schools not doing a better part of divorcing themselves from being an extension of undergrad). We need to make the fact that residency is an apprenticeship more palatable somehow without catering to folks' desire to do less work with less stress and more passive education. I think the approach so far is to try to screen for folks who know this instinctively (and the millennial stereotype certainly doesn't apply to everyone) but to not acknowledge that it's an issue is going to become a problem as the years roll on. I don't see the trend changing anytime soon.

 

[MLT2MT2DO]

To be fair, a lot of the interview reviews paint him in a slightly negative light. Perhaps he just doesn't "interview" well?

Most of the negative reviews focus on him "not being serious enough". From only 30 minutes of interaction I can see how someone may get this impression, he likes to joke and is very personable.
Again, I clearly like the guy, and repect others might not, but apathetic/unenthusiastic I can't see.

 

[Armadillos]

Yep. I feel like the "millennial issue" is kind of the 800# gorilla in medical education right now. It's tough, because we are obviously talking about generalizations and many folks of the generation won't fit with the description. But it's also hard to not see the gross differences between folks in their late 20's vs in their 30's or 40's. I noticed it in medical school and can see it in residency as well and I've yet to see someone in their 30's/40's also not see the difference.

The thing I struggle with most is the change of how "service" has become "service without sacrifice" or "service on my own terms." This is likely accentuated by the fact that folks going into medical school tend to come from socioeconomic classes where a sense of entitlement is more prevalent anyway. But it's still a bit hard to swallow sometimes when folks seem to want to wave the banner of public service but not want to bear the trappings of public servant. I also notice many folks often fight a lot harder over slights and perks as residents than they do over issues of medical care and patient wellness. The predominance of this also seems to be inversely proportional to age, which is interesting as creature comforts and the like is something I would more typically associate with us older farts.

Residencies are going to have to develop a better way to market what residency actually is to millennial folks. I notice the disconnect is often thinking that residency is somehow an extension of medical school (which is in part the fault of medical schools not doing a better part of divorcing themselves from being an extension of residency). We need to make the fact that residency is an apprenticeship more palatable somehow without catering to folks' desire to do less work with less stress and more passive education. I think the approach so far is to try to screen for folks who know this instinctively (and the millennial stereotype certainly doesn't apply to everyone) but to not acknowledge that it's an issue is going to become a problem as the years roll on. I don't see the trend changing anytime soon.

I think its pretty shortsighted to boogeyman millennials, specifically high performing millenials like medstudents, lawyers, engineers,etc. Sure there are millennials playing playstation on their parent's couch, but thats not who we are talking about.

People who are now in their 40s-60s grew up in an extremely comparatively inefficient society when it came to information transfer. The world is changing, and throughout society high performers are now much more interested in working smart than following traditional paths. Look at current medstudents and resident's CVs compared to 30 years ago, today's generation is incredibly productive. Millennials want to work hard, they just want to work hard on their own terms and not fit into some premade cookie cutter.

More and more programs are harnessing this, they are building in more and more elective and scholarly time throughout their curriculums and as you can see folks like smallbird are using it to great effect. So yes there needs to be a change, but its not going to be the millenials. The old school places are going to get left behind at some point if they are not willing to adapt. Just look at radioshack.

Edit: And from a service standpoint, many millenials can look around the western world and see the best way to serve our patients collectively is not through individual docs working 80 hours a week, its through improvement of healthcare systems. The USA was getting away with having massive systematic inefficiencies partially because for so long docs were willing to sell their souls to the system (and were paid handsomely to do so).

 

[MacDonaldTriad]

And from a service standpoint, many millenials can look around the western world and see the best way to serve our patients collectively is not through individual docs working 80 hours a week, its through improvement of healthcare systems. The USA was getting away with having massive systematic inefficiencies partially because for so long docs were willing to sell their souls to the system (and were paid handsomely to do so).

"It has been said that democracy is the worst form of government except all the others that have been tried."
Winston Churchill

Well our health care systems and graduate medical education systems are flawed, inefficient, and could stand to be improved considerably. They are also the envy of all other health care systems. Costs are high, but so is the quality, and we are answering by far the most research questions, save some epidemiological examples in socialized medicine.

 

[Armadillos]

"It has been said that democracy is the worst form of government except all the others that have been tried."
Winston Churchill

Well our health care systems and graduate medical education systems are flawed, inefficient, and could stand to be improved considerably. They are also the envy of all other health care systems. Costs are high, but so is the quality, and we are answering by far the most research questions, save some epidemiological examples in socialized medicine.

That last bit was more of a side point, just pointing out that physicians in europe still manage to provide amazing care to their populations as a whole despite the fact their medical training model is much different than the one older american physicians went through. So when millenials hear older physicians say we need to train a certain way in order to become competent because thats how they trained, we are skeptical.

The ironic thing is that the old guard opened medicine up to the onslaught of mid-level encroachment because society and the market could easily recognize the blatant inefficiencies of medical training as a whole and other professions were observant enough to exploit them to advance their profession.

 

[MacDonaldTriad]

I mostly agree, but only to a degree. Students are not very equipped to know what and how they need to learn subjects they have not mastered yet.

The need to advocate for change and improve things doesn’t change with age, only the targets change. Med school to graduate education, grad ed to hospital administration, hosp. admin to the state and CMS…. No matter where you stand, it is always possible to have an internal dialog that wonders; “why don’t they fix this, if I were in charge, I would fix it…” Sometimes I wonder if all of this change has improved things, or maybe things would be much worse if we didn’t make changes. Probably most changes are more helpful than harmful, but more in a 60/40 kind of way than we like to admit.

 

[Armadillos]

I mostly agree, but only to a degree. Students are not very equipped to know what and how they need to learn subjects they have not mastered yet.

The need to advocate for change and improve things doesn’t change with age, only the targets change. Med school to graduate education, grad ed to hospital administration, hosp. admin to the state and CMS…. No matter where you stand, it is always possible to have an internal dialog that wonders; “why don’t they fix this, if I were in charge, I would fix it…” Sometimes I wonder if all of this change has improved things, or maybe things would be much worse if we didn’t make changes. Probably most changes are more helpful than harmful, but more in a 60/40 kind of way than we like to admit.

I agree completely. I'm very much of the millennial mindset in general, but that doesn't mean I think all the change in medical education has been good.

For example, from an efficiency standpoint, its appalling how much administrative time and medstudent/physician energy goes into proving that all medstudents had X experience or whatever. You have medstudents carrying around log books to prove an attending (a fellow doesnt count) watched them palpate someones abdomen or ask a patient if they have any spiritual needs. Then you have admin staff collecting all these log books and then matching them up to whatever objectives the LCME made them invent for each rotation. Then the medstudents have to write some paper about how they collaborated with another profession or some BS. Its really gotten to the point (and rightfully so from a medstudent's perspective, because ultimately the most important thing is to check all their boxes to pass) that a student needs to make decisions like stalking an attending all day to get something trivial observed then going to some lecture series on cultural competency, instead of actually being a part of the team seeing new patients.

 

[notdeadyet]

I think its pretty shortsighted to boogeyman millennials, specifically high performing millenials like medstudents, lawyers, engineers,etc. Sure there are millennials playing playstation on their parent's couch, but thats not who we are talking about.

This is basically a cross-cultural issue. Millennials are a cultural group that operate under a stereotype that is unfairly applied. Some stereotypes are exaggerations of generalizations. So when any criticism is made of this cultural group, those to which its applied recoil and assume the stereotype is being applied to them rather than discuss the very real fact that every generation is different from the next and (in this case) it needs to be taken into account when teaching them. No one is talking boogeymen. That interpretation is why it's an 800# gorilla.

People who are now in their 40s-60s grew up in an extremely comparatively inefficient society when it came to information transfer.

True. But do keep in mind that it is people now in their 40's-60's that recognized this fact and implemented the changes in information gathering, interpretation, and distribution that you're taking advantage of.

Millennials want to work hard, they just want to work hard on their own terms and not fit into some premade cookie cutter.

I think the bold is the root of the issue here. You haven't earned the right to your own terms. I'm in my 40's but am still a resident, so I haven't earned the right to my own terms either. You need to have exposure and (more importantly) extensive experience with the systems in place to make substantial and sustainable change. The idea of cutting your own path may be brilliant. Or it may have been repeatedly tried and failed for reason you don't understand (lack of experience). The idea of learning on your own terms is certainly appealing, the fact is that the learner isn't in the best position to know the best way to teach the subject. And while the learner may be okay with that, since it will hurt patients downstream if you don't learn it right, that's not a suitable risk. The better programs will take your feedback on the learning process very seriously and implement incremental and thoughtful changes followed by quantitative analysis and iterative modifications. The great programs will give you the tools to become a subject matter expert and thought leader in the field and inspire you to go on to careers in medical education in which you can leverage your intelligence, creativity, and experience to turn things on their ear. But you're not there yet and you don't know what you don't know.

Folks sometimes listen to heavy metal and say, "it's just noise... anyone can play that..." They are then shocked when they see the tatooed longhaired guitarist knock out some incredible classical music piece on a nylon string. The best way to break the rules and cut a new path is when you've learned the well-worn path well. Otherwise... noise.

More and more programs are harnessing this, they are building in more and more elective and scholarly time throughout their curriculums and as you can see folks like smallbird are using it to great effect. So yes there needs to be a change, but its not going to be the millenials. The old school places are going to get left behind at some point if they are not willing to adapt.

Agreed. The better programs are using more self-directed learning, case based work, online training, advocacy training, and all sorts of things that were not commonplace 10 years ago. Mind you, most of these started 10 years ago. I have no doubt that we are going to see an acceleration of different modalities and educational technologies and techniques in the coming years that will come to be as folks in the millennial generation are taught how to be good clinicians, thought leaders, and scholars. But you have to walk before you can run. The resistance to learning to walk first is something that many think will need to be carefully addressed.

 

[notdeadyet]

For example, from an efficiency standpoint, its appalling how much administrative time and medstudent/physician energy goes into proving that all medstudents had X experience or whatever. You have medstudents carrying around log books to prove an attending (a fellow doesnt count) watched them palpate someones abdomen or ask a patient if they have any spiritual needs.

Boy, I sure agree with that. You might be surprised that attendings and other folks in the educational process hate log books (almost) as much as medical students.

You know why it's necessary? Because without it, folks were not doing the tasks requested. And I have a hunch more than a little of this comes from folks wanting to do things "on their own terms." They don't think addressing spiritual needs is important so they don't do it. Log books and verification that educational tasks were completed is a relatively new phenomenon.

This is the blowback. And this is why the different strengths and weakness, capabilities and drawbacks, of each generation needs to be addressed in the medical education process. If we could talk about this stuff openly, we can find a handy way to problem solve. Instead, we have the 800# gorilla. And log books.

 

[Armadillos]

I think the bold is the root of the issue here. You haven't earned the right to your own terms.

I think this is the thing that really grinds the "high performance" millennial. Medicine is such an oldschool hierarchy, its like a union that values time put into the system instead of performance. Nobody is given the opportunity to earn the right to their own terms by individual performance, the best of the best and the bottom of the barrel both go through the exact some mold.

For example in internal medicine, my program was particularly weak in a couple sub-specialties, but had many extremely good general medicine residents. So you have situations where there is an incredible PGY3 who is going to MGH next year for fellowship, but they are stuck bowing to every whim of the PGY4 fellow who was scrambling around to go anywhere that could take him.

I distinctly remember a friend in highschool getting a call from some exec at google/apple who had seen his work online. Next day he is flying to Cali, interviews wearing a pair of shorts and flip-flops and is working from his dorm room for them over the next 4 years.

Where is the opportunity for that in medical training? The research side of medicine allows the ability for skill to be demonstrated and valued accordingly. But clinically and administratively its all about punching that clock until your senior enough to be deemed worthy to do X.

 

[Armadillos]

You know why it's necessary? Because without it, folks were not doing the tasks requested.

IMO the difference was that back then nobody was systematically asking if every single med student had done all this stuff. (See House of God- Rule 1o. )

I can assure you none of my trauma surgery attendings spent their training in the 1980's taking spiritual histories

 

[notdeadyet]

I think this is the thing that really grinds the "high performance" millennial. Medicine is such an oldschool hierarchy, its like a union that values time put into the system instead of performance. Nobody is given the opportunity to earn the right to their own terms by individual performance, the best of the best and the bottom of the barrel both go through the exact some mold.

The problem is that you haven't really performed yet. Medical school is essentially preparation for starting training.

In residency, you will have to go through the same base training as your peers, but your experience will vary greatly. If you have more ambition, talent, and passion, you will be afforded more opportunities and get more out of the training than someone less inclined. You will have the opportunity to succeed and you're about to step up to the plate.

The research side of medicine allows the ability for skill to be demonstrated and valued accordingly. But clinically and administratively its all about punching that clock until your senior enough to be deemed worthy to do X.

I think you'll like where medical education is heading. Google Entrusbable Professional Activities sometime. The field is going to be moving more and more away from what you view as punching the clock and more about demonstration of excellence.

In regards to your friend at Google: they will start him on projects that feel very important but in fact it will be more redundant and have more eyes on it than he thinks. And at the end of the day, when he f--ks up, nobody dies.

 

[Armadillos]

I think you'll like where medical education is heading. Google Entrusbable Professional Activities sometime. The field is going to be moving more and more away from what you view as punching the clock and more about demonstration of excellence.
.

Thanks i'll definitely look into it more, although the cynic in me fears that will just become another administrative boondoggle and residents won't actually differentially get any more autonomy/experience sooner than each other, it will just be one more thing they are required to do by the end of PGYx year. In the pie in the sky Armadillos system, it should be possible for a PGY3 to be "senior" to a PGY4 if the PGY3 is the better doctor.

(And none of this should be interpreted as me thinking I'm some star performer, I don't have any fantasies that I would be the one to be jumping over my more senior trainees, I fit well where I am. But I can recognize others being held back by the system.)

 

[slappy]

Yeah, I think this dichotomy still eludes me. You'd get instantaneous approval at my place, but there are also policies that make that possible. If you're one of two residents on an inpatient team, for instance, you don't take vacation at the same time other than the holidays.

I didn't quite mean to imply a rigid dichotomy. I guess there is definitely a spectrum, and a significant number of programs I'm intimately familiar with skew towards the "resident-independent" end. Most of these programs are in the east coast and "eastern" midwest, and almost all are generally regarded among the best in the country.

To illustrate a difference based on your example, at the inpatient rotations at my program, you are given enough freedom to head the team and manage your patients as you see fit (as long as you can scientifically back your decisions) with the attending acting entirely in a supervisory role until you are out of your depths and request their help. But at the same time your leaves would get approved at a day's notice, with the attending taking over from where you left off. Naturally this assumes you write excellent notes documenting your entire thought process and the complete plan. I guess that's the only policy in place. The attending being always aware of what is going on is also a requisite, but that's usually a given.

Whether or not the other resident is also on vacation doesn't quite matter since the teams are entirely separate, and the residents don't cover for each other unless you're on one particular block where you take turns to do the H&P on new admissions over the weekends (along with medical students) to help ease the work of the attending on call. I'm not quite sure what would happen if both residents need to be away one weekend. I suppose life would go on just fine since the residents on average do one H&P per weekend day of call, which probably translates to a grand total of one hour of extra work for the attending over the weekend.