The case for training at an "elite" institution

[fatboy]

After reading several threads which either started on this topic or eventually touched on it peripherally, I wanted to reiterate two of the benefits of training at “elite” high volume academic centers.
1) Affiliated with a major cancer center. For the most part, this means that there is a prominent selection bias of patients with common and uncommon tumors/processes featured in nearly every subspecialty. As a result, you are exposed to a variety of routine and complex specimens. You are also exposed to the follow up and/or treated specimens from these patients. This should translate into proficiency at triaging, grossing, working up, diagnosing, grading, and staging these cases. Additionally, this usually means that attendings on both the path and clinical side are familiar with current grading/staging paradigms, pitfalls, and important prognostic features. If you end up at a major cancer center, this training will help you fit right in. If you end up in the community, this training will give you the confidence that you need to stand up to clinicians who may not be completely up to date with current protocols.
2) Receive lots of consults across many disciplines. This is very important because I would imagine that nearly every ACGME accredited program can sign out and teach the trainee to sign out at least 90-95% of routine/bread and butter biopsies and resections. The problem is that not every program routinely signs out or receives exposure to the 5% of unusual cases: unusual benign processes, common cancers in uncommon locations, rare cancers, cancers that look benign, benign masses that look like cancer, variants of common malignant tumors etc. At major academic centers where community pathologists seek expert opinions, your exposure to this 5% of cases increases exponentially. Reviewing these consults are challenging and often take 5-10X more time and energy to work up and sign out. I agree that reading and reviewing study sets may help. However, there is no substitute for struggling through these live cases with an “expert.” It helps you develop focused differential diagnoses, an understanding of the pitfalls, and, ultimately, the diagnostic acumen that you need when you end your training. When you are an attending, these atypical and bizarre cases are the ones that will give you a lot of stress. But even more concerning are the benign looking cases that are malignant because this usually means that the patient is given a clean bill of health when they should be receiving treatment.

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[Mud]

Although I am not yet at the stage to speak from personal experience, I can speculate a few more reasons. The faculty at elite centers are more likely to have extensive connections. Whatever you want to do after residency, it doesn't hurt to have an attending who knows someone. If there is a big name in your program who will be your reference, that may also carry more weight than Joe Schmoe, MD. Finally, future employers may look at training programs as screening mechanisms; if you were good enough to get into a top program, that probably means you are a good student.

 

[scienceguy19]

What about the stress of training at an elite institution?
I imagine that attendings expect close to perfection from residents and can be overly critical.
I don't work well in a high pressure environment.

Although I am not yet at the stage to speak from personal experience, I can speculate a few more reasons. The faculty at elite centers are more likely to have extensive connections. Whatever you want to do after residency, it doesn't hurt to have an attending who knows someone. If there is a big name in your program who will be your reference, that may also carry more weight than Joe Schmoe, MD. Finally, future employers may look at training programs as screening mechanisms; if you were good enough to get into a top program, that probably means you are a good student.

 

[KeratinPearls]

Not every "elite" program is a good program. You want to be able to enter a diagnosis for the cases you gross. I know there are some "elite" programs out there where you gross a case and the case is taken from you and signed out by the attending. I agree that you may have better connections from an elite program, that is, if you are a good resident.

 

[deleted314957]

Although I am not yet at the stage to speak from personal experience, I can speculate a few more reasons. The faculty at elite centers are more likely to have extensive connections. Whatever you want to do after residency, it doesn't hurt to have an attending who knows someone. If there is a big name in your program who will be your reference, that may also carry more weight than Joe Schmoe, MD. Finally, future employers may look at training programs as screening mechanisms; if you were good enough to get into a top program, that probably means you are a good student.

as someone who has hired pathologists in pp that is not my experience at all. we did not really care where someone did their residency. we looked for board cert (ap/cp), experience (post training experience) and a winning personality with great communication skills----period.

 

[pathstudent]

I would say the best reason to go the the biggest baddest medical center would be access to fellowships. Bigger places will have more choices with more spots and internal candidates always have the upper hand.

 

[cjw0918]

Elite or not, there is also a certain hometown advantage that programs have. If you are dying to live in a certain city for family reasons, I think it's worthwhile to consider doing your residency there. Pathologists who live close to each other geographically tend to know one another and many locals even trained together. Connections cannot be overstated.

 

[KCShaw]

While most of this is more or less true, it doesn't always translate into the "next step", whether that's fellowship or practice. One of the problems, of course, is that "elite" is haphazardly applied and means different things to different people -- making it generally meaningless.

That doesn't mean the points raised aren't reasonable ones, because certainly I can agree that high volume could mean a broader exposure to more cases, both common and uncommon. More consults to the institution should mean more difficult cases, and attendings with enough clout/confidence/experience to reasonably sign them out. As pointed out, though, just because the department sees them doesn't mean the residents see or learn from them -- though at least the potential is there. This is why it's generally more useful to talk about not only the size of a program, the kinds of cases and consults they get, and the notoriety of the attendings, but also how that relates to the residents and fellows, how or whether they interact with the attendings, grossing time, preview time, graduated responsibility, and so on and so forth.

 

[icpshootyz]

I think some of the best advice I got early on was to go to the best possible program at each stage of my training. You do have to think of how that will affect your lifestyle, etc, but the name of your residency and your fellowship(s) will be on your CV forever, and the better those names are well, the better. I'm not saying it'll open all the doors, or make up for your own personal flaws/faults. But if it comes down to you and someone very similar in most ways to you and you have the better pedigree, then hey, good for you.

 

[pathstudent]

I think some of the best advice I got early on was to go to the best possible program at each stage of my training. You do have to think of how that will affect your lifestyle, etc, but the name of your residency and your fellowship(s) will be on your CV forever, and the better those names are well, the better. I'm not saying it'll open all the doors, or make up for your own personal flaws/faults. But if it comes down to you and someone very similar in most ways to you and you have the better pedigree, then hey, good for you.

All else being equal, namebrand matters. It is common sense and it is a fact of life.

 

[sirenomelia]

Ive had colleagues, attendings, trainees from Duke and Mayo who were aloof and dumb as a box of rocks, and also Carib grads and IMG's who were top notch. If you are so insecure as to need a foofy name superlative on your diploma then go ahead by all means but people in the real world know it doesnt mean much in of itself.

 

[KCShaw]

Again, what defines "best" in this setting is what one probably needs to focus on.

 

[fatboy]

Again, what defines "best" in this setting is what one probably needs to focus on.

My point is that elite training programs can be found based on semi-objective benchmarks. They are associated with a cancer center (comprehensive cancer center >cancer center, see http://cancercenters.cancer.gov/documents/ccc_list.pdf) and they have lots*of experts across many disciplines (neuro, derm, heme, gi, gyn etc.).*
IMHO, these are important raw materials for training and ultimately gaining proficiency in pathology.*To use brigham as an example: associated with Dana farber cc + a ton of experts such as Aster (heme), Fletcher (surg path, soft tissue), Lester (breast), Odze (gi), Crum (gyn) = elite. If I had to do it over again, that is how I would go about choosing where to train. I would use the interview process to tease out whether residents have access to the experts and their material, location, quality of life etc. The cream will rise to the top.

These features may or may not have anything to do with landing a job. If you want a job, connections help and you cannot be a jerk. A jerk who trains at Stanford may not get a job, however the same jerk is unlikely to land a job if he trains at a non-elite program.*

 

[LADoc00]

I once thought bigger, badder best rep medicine was the way to go...

After being in practice now for quite awhile, Im waiting to see ANY difference whatsoever graduating from UCSF, Harvard-Brigham, Hopkins, Washington, Stanford or UCLA etc makes.

I have not seen it for any of the graduates once you fast forward 5+ years out of training. Yeah some of the better known programs have more research types that....well, go into research, but for everyone else my anecdotal evidence suggests you should focus on social skills and just pick a training location in an area you would be happy living near...

Social skills, ability to perceive and capitalize on business opportunity and flexibility appear to be the prime determiners of success and happiness once residents and fellows leave training and these characteristics seem to be independant of where people trained.

In terms of getting exposure to quality teaching cases, almost any med center can provide that. Ive found that even at the "best" programs many residents now are lazy and dont learn what they need to be competent day 1 after they leave. Their first job with independance seems to be where they grow the most.

 

[Wernicke]

"Beauty is only skin deep." "That's just something ugly people say." -Liar, Liar

 

[Rodak]

Focus on the question, "what exactly do residents do?" Do residents learn by primarily doing what the attending would be doing as much as is legal or by primarily observing, reading, or listening to a lecture (or, god forbid, being a secretary or PA)?

3 must-ask questions:
1. Do residents write/dictate reports, final diagnoses, and comments that attendings sign out? Not just the gross. Not just autopsies.
2. Do attendings sign out reports that residents did NOT write? What percentage and in what areas?
3. Do tasks/conferences/calls from techs/docs go to attendings directly without going through the resident? What percentage and in what areas? Another way to ask these types of questions is: how exactly do the resident's clinical duties differ from the attending's? The best answer is "the attending presses the sign button when I'm done."

I call "elite" programs those that graduate residents who were provided with the responsibility and authority to practice acting like pathologists. Employers know which "have" and "have not" programs these are. The list of "have" pathology programs that train residents properly doesn't necessarily overlap with the list of top few research med schools, hospitals, or path depts (although they often do). Given the job market, you need to be from a "I did it" program instead of a "I observed the attending doing it (if at all)" program.

 

[Dr. Pepper]

I have a question about name-brand programs and fellowships. I know that there are a lot of pathologists on this board who say that the job market right now is terrible for pathologists. Do you think that going to a name brand program would significantly help someone during the job search? Also, does this apply to academic medicine as well (ie: getting a faculty position out of fellowship)?

Thanks so much.

 

[KeratinPearls]

I have a question about name-brand programs and fellowships. I know that there are a lot of pathologists on this board who say that the job market right now is terrible for pathologists. Do you think that going to a name brand program would significantly help someone during the job search? Also, does this apply to academic medicine as well (ie: getting a faculty position out of fellowship)?

Thanks so much.

Are you premed? If so, worry about getting in med school first. You are thinking waaay ahead. Whatever you do, always aim as high as you can and go to the best program/school you can. Also, it helps to be happy wherever you go.

 

[Dr. Pepper]

Are you premed? If so, worry about getting in med school first. You are thinking waaay ahead. Whatever you do, always aim as high as you can and go to the best program/school you can. Also, it helps to be happy wherever you go.

Sorry about the status. I'm a 3rd year med student and I've been considering pathology since 2nd year. I"ll do a rotation in it in 4th year but, as you can imagine, I'm a bit eager to get information before then.

 

[KCShaw]

Better is better, just everyone's definition or list of better & best isn't identical. People keep trying to generate a list on this board and no-one seems to consistently agree beyond the concept that a small number of programs are so-called top-tier, a bunch of programs are mid-tier, and a small number are lower-tier. But beyond, I dunno, a half dozen or so programs it seems like everyone argues over where the lines are drawn -- and it probably doesn't matter. Everyone learns in different ways or gets frustrated/burned out by different things, which also makes certain programs better or worse for them as an individual. I think having a name brand generally helps and very rarely hurts, but as for how much and whether that's "significant" is a bit too vague. I tend to agree that it's worth aiming high, while realizing that any decent sized mid-range program isn't exactly hurting you in the long run either, so long as it reasonably suits you as a resident.