To those who are applying for GS, a little unsolicited advice

[dr.evil]

As I progress through my intern year of general surgery, I try and help the 4th year students at my current institution with applications, places to apply (and not to apply), and what to REALLY look for in a program. I thought I would drop a little of this here on the forum.

I think as an applicant I often looked at the call schedule, the case numbers, community vs. academic, fellowship matching potential, how the residents got along, and how much they saw the O.R. prior to their 3rd year of residency. There were other things but they were more specific to my situation (married with a kid).

So, what's really important. I have to say that fellowship matching should be at the bottom of your list (although some will disagree). No matter what program you come from, matching into any fellowship of your choice (other than pediatric surgery) can be achieved at any program. You can go to BFE in southeastern illinois for GS and still match at Baltimore Shock for Trauma. It happens all the time and is not a rarity.

At the top of your list should likely be AUTONOMY. There are so many programs where you don't ever see an attending except for the "critical parts of the procedure" while other programs have an attending hovering over you when you put in a central line. Community programs tend to be have a little more hands on from the attendings (cuz they get paid more for the procedure if they are "present and scrubbed for the entire case") while academic programs for the most part are hands off. This is a generalization but you need to ask these things on the interview trail. What do I think is best? Well for your first 3 years, it's nice to have the attending hovering over you, critiquing your moves, and giving you input on how to improve. But for the 4th and especially the 5th years, hands off is definitely better. So a graduated level of autonomy is probably best. I can't stress autonomy enough. I felt that my medical school program was very hands off while my residency program is too far on the hands on side.

Call schedule and hours will be of very little concern overall if this whole 80 hour work week is solidified. BTW, there is a HUGE difference between q2, q3, or q4.

How the residents get along: Extremely important. You can usually see/feel this interaction during the interview. You have to work with these guys for 5 years.

Getting in the O.R. during your intern year is icing on the cake. You tend to get really bitter if you go into a specialty and you don't even get to practice the type of medicine you want. I've done 2 solo lap choles, 1 lap appy, a modified radical mastectomy, and some other basic cases in my first month and half. This helps you remember why you're staying at the hospital >100 hours/week.

Anyway, there's other stuff and I'll add it if wanted but you get my drift. There's more to a program than what's on FREIDA and it's extremely difficult to evaluate in a one day interview.

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[IBDCURE]

Dr. Evil,
Thanks for the unsolicited advice- I am a MS-IV who often is rooting around here looking for tips/stories on what to keep an eye out for in GS programs.

I am having a few dilemmas; the first of which is what I want to do when residency is over. I don't have much experience in things like plastics, transplant, or oncology yet, although I could definitely see them being very interesting. On the other hand, I have enjoyed GS quite a bit and think I'd be quite happy doing it as well. And although I am just one notch above being the low man on the totem pole as a MS-IV, over the last few months (since the new MS-III's and some pre-meds have started) I've been surprised to find that I really enjoy teaching new people.

So right now, I'm not sure how to present all of this on a personal statement. I don't want them to think that I am an unfocused 20-something bum, but I couldn't honestly say that I definitely want to go for fellowship X versus Y or into private practice.

I don't know how competitive I am; I had a little too much fun my 1st and 2nd year and ranked between the top 1/2 and 1/3 of my class, and I studied (but not as hard as I should have) and got a 230 on Step 1 (good but not great). However, I really enjoyed 3rd year, aced all of my rotations, and ended up near the top of the class (for 3rd year.) I'm working really hard on studying for step 2 and really hope I can beat a 240 (I take it in a week).

I'm looking at some (roughly) Mid-Atlantic/Southeast area programs now; have been eyeing UNC-Chapel Hill, U. of Florida, Medical College of Virginia, Eastern Virginia, U. of Tennessee, U. of Louisville, LSU, U. Maryland to name a few. I'd also like to check some out in NY and PA but am very unfamiliar with what is up there. I don't know much about community programs but am planning to check some of those out as well. For the ones I listed, anyone know about their competitiveness? (I feel left in the dark about how to judge that.)

I don't care so much about the most prestigious/big name thing; I want a program with excellent teaching and experience for the resident. I want to know my stuff and be very good at it when I finish so I can offer the best care that I can to patients. I'm easy to get along with, I work very hard, and I work well in groups, so I'd like to be in a place where that's true of the residency as well.

Okay, I've asked more than my fair share of questions; again, the time you all squeeze in from your busy schedules to answer any of these things is much appreciated!

 

[dr.evil]

IBDCURE,
I think you have listed some very good programs of which some of the members of SDN are either residents or former residents. I also feel that simply by numbers, you are very competitive for most programs throughout the nation. My numbers were very similar and I was given interviews at every place I applied.

Even though most interviews will ask you what you think you will be doing in 5 years (fellowship vs. practice), very little weight is actually put in to that. They just want to see your initial interests or if you are open for anything (which is actually a pretty good way to be.)

I try not to rate programs overall because no one really knows how good a program is unless they have trained in several programs. The majority of surgery programs will provide you with very good training but will achieve this goal in a variety of ways. Try to figure out what type of environment you learn best in. Do you prefer more structure or leniency? More didactics vs. more reading at home? Students vs. no students?

There's just a lot to consider. I don't think you should consider competitiveness much. You'll be OK.

I went the very vague route on my personal statement. My goal was simply to show my ambition for GS and any opportunities it may present to me in the future.

Enjoy the process. I'll be around to ehlp you out if I can.

 

[surg]

Nice summary of advice. I want to echo a few things.

You can get excellent training from probably >90% of the programs available today. The choice of program should be based more on where you fit in rather than prestige. Still, in the end analysis if you fit in somewhere that happens to be prestigious, well, you can do the math.

As far as getting into fellowships, while they have gotten dramatically easier to get a spot, it is still my belief that those who are at academic institutions tend to have a slight advantage since their advisors will often know more people in that specialty and can give you better advice and smooth over some bumps that you might run into. This is particularly true when you are looking for fellowships in specialties that don't train a lot of people in each year (ped surg, surg onc, even transplant to some extent).

To the issue of autonomy, I think there is a fine line here. As Dr. Evil said, you don't want someone breathing down your neck, but at the same time you don't want to be hanging in the breeze when you aren't truly fully trained yet. I often think that all programs should have a county or VA experience because the autonomy is so much greater there and the pathology so much more advanced.


Finally, for IBD. Your statistics should more than get you through the door for an interview at _any_ program in the country, assuming that your letters from your clinical rotations match up with your grades. All the programs that you listed should provide you with fine training. The best advice I can give you is to talk to the interns at your school and get their impressions of the places (I hesitate to give you any of mine since I haven't been to any of those places in a while) and most importantly sit down with your letter writers with your list and have them tell you their impressions. Often your chairman or program director knows the scuttlebutt as to who is staying and who is leaving certain institutions.

 

[IBDCURE]

Hi Dr. Evil and surg-
Thanks for the advice- I really find advice from you guys who can look at it in retrospect very helpful. I've been trying to identify the sort of things that as a 4th year I may not be thinking about but in a year from now I wish I would have known.
Did you guys get much of a chance to meet with residents and faculty during interviews? Is it normal for programs to have dinners/ receptions during interviews? After I take Step 2, I'm going to do 2 sub-internships, but there are lots of other programs out there I'd like to have the chance to check out as well. I guess, like interviewing for medical school, it's hard for you to get to know a program/them to get to know you in a day.
Again, thanks for the advice- I now feel better about my competitiveness as an applicant (sometimes I wish I'd buckled down a little more 1st year, but it's good to know that I'll have a shot at getting to interview/check out what's around.)

 

[njbmd]

Originally posted by IBDCURE
Dr. Evil,
Thanks for the unsolicited advice- I am a MS-IV who often is rooting around here looking for tips/stories on what to keep an eye out for in GS programs.


I'm looking at some (roughly) Mid-Atlantic/Southeast area programs now; have been eyeing UNC-Chapel Hill, U. of Florida, Medical College of Virginia, Eastern Virginia, U. of Tennessee, U. of Louisville, LSU, U. Maryland to name a few. I'd also like to check some out in NY and PA but am very unfamiliar with what is up there.
Okay, I've asked more than my fair share of questions; again, the time you all squeeze in from your busy schedules to answer any of these things is much appreciated!

Hi there,
I loved University of Maryland, University of Virginia, Wake-Forest, and did not like Eastern Virginia. I have heard good things about UNC-Chapel Hill but I did not apply there. I ended up at University of Virginia and I am in heaven! I interviewed at Medical College of Virginia and ranked it lower than UVa but generally liked everything except Richmond.

Here at UVa I started with Vascular Surgery, then Surgical Oncology. I have gotten plenty of OR experience with great attendings who love to teach. There are plenty of intern-level cases. The didactics are off the scale! The residency director is a great teacher who is dedicated to making sure that the residents have what they need for learning. He is totally awesome! The hospital is computerized and has a good trauma experience (mostly blunt but an occasional gunshot wound). There are plenty of PA and nurse practictioners to do things that are of less learning value to residents. I have cross covered and managed transplants, cardiac, and thoracic patients. I have rotations coming up in colo-rectal, laproscopic, hepato-biliary,thoracic, cardiac, SICU & Burn Unit and the VA Hospital.

The department chairmen (we have two) invite us for fly-fishing trips and other social affairs. I have a very tight group of fellow residents who are diverse and good to work with. The chiefs are great folks and allow us to get plenty of cases at the intern-level. People match in the fellowship of their choice here. The president of the American College of Surgeons is on faculty here. The pace is not break-neck but steady. There is protected time for didactics where you are not having to leave conference to take care of floor duties. All of the support services are excellent. You don't do scut here in any form.

If there is a down side here, it is that the average educational level of your patient is 5th grade. Charlottesville is a college town but outside the town limits is rural farm country. The drugs of choice among the locals are alcohol and tobacco. Housing is cheap and plentiful. You are 100 miles south of Washington, DC and about 60 miles east of Richmond, Va. Lot's of skiing, hiking and other outdoor events here. The program is also 7 years counting the research years so take that into consideration.

I was looking for a university-based program with good didactics. I also wanted to stay on the East coast. I didn't like the community programs like Washington Hospital Center and St. Agnes in Baltimore. I also interviewed at Mayo, Minnesota and Hopkins but couldn't stand the cold of Minnesota or the environment of Hopkins (neighborhood is rough and housing is expensive). I also liked the University of West Virginia at Morgantown. It was just a little too small for my tastes. The chairman at WVa is great and has good connections for fellowships.

Good luck with your interviews!
njbmd

 

[dr.evil]

Did you guys get much of a chance to meet with residents and faculty during interviews? Is it normal for programs to have dinners/ receptions during interviews? After I take Step 2, I'm going to do 2 sub-internships, but there are lots of other programs out there I'd like to have the chance to check out as well. I guess, like interviewing for medical school, it's hard for you to get to know a program/them to get to know you in a day.

You do get to meet quite a few of the residents during the interview process. Although, during the actually day of the interview you don't really spend as much as you would like. Most of the contact usually comes the night before at either an informal dinner/reception or a more formal one. I definitely preferred the more laid back get togethers because I felt I could ask a lot of questions. You really don't get much interaction with faculty other than interviews and sometimes lunch that day.

It's definitely difficult to choose the 2 places you do your sub-I's and even more difficult to evaluate programs in a one day interview. The advantage of the sub-I's is that you not only are able to evaluate those 2 programs but are able to create a more well-defined list of wants and "not-wants" from a program. You'll be surprised on how different each program really is with their styles.

 

[IBDCURE]

Hi guys-
Sorry it has taken me so long to post- I just arrived in a new city 1,000 miles away from home to do a surgery externship. I finally have some computer access set up.

The people I have been talking to (I'm at a university program) have been great, but have expressed the same sort of things I have heard at my medical school, such as not getting into the operating room much at all until 3rd year. I'm so confused now; I wish I could look into the future 10 years to know exactly what I want to focus on. I absolutely love being in the OR (I guess we all probably do) and would like to have tons of cases under my belt before finishing residency. And I'm sure no one likes to do scut; I'm not crazy about the idea of 2 years where it makes up about all of what you do. I also am tossing the idea around about surgical oncology; don't have much experience with it yet, but the oncology cases I have gotten to participate in have been some of my favorites.

What do you guys think of community versus academic training in terms of hands-on experience and teaching? Any advice on programs to check out? Any advice is appreciated!

 

[droliver]

If you plan on doing a competative specialty fellowship (Oncology,Plastics,Peds, or Vascular) you are almost always better off coming thru a university-based program. Otherwise, you can get adequate training for general surgery @ any number of places. I personally would not enjoy being in a private-community program because of the politics that go with it often times at private hospitals. We probably spend about 1.5 years out of our 5 years on services that function like a private program, & although you acquire lots of #'s of cases on them, I think most people don't really enjoy the working arrangements that go along with it. It's my firm belief that you need a good VA &/or indigent experience to complement your training.

It's hard to generalize whether you get better training @ University or Community programs (I think overall that I'd throw my lot with the former) because not all university programs are equal on the oppurtunities they can provide you. For example, there are a # of "name" university programs affiliated with the Ivies & other private medical schools that have very poor training programs by reputation.

It sounds like you have made a good plan by doing an externship, you can really get a look-see @ some other programs first hand as well as giving you more basis to compare b/w other programs & your medical school. Talk to the people who just went thru the match & get feedback & impressions from them on where they visited (Take a little of it with a grain of salt as some people get turned off on some places fo rthe silliest reasons)

 

[dr.evil]

Although I somewhat agree with droliver, I felt the exact same way as IBDCURE about OR time in my first 2-3 years. Therefore, I chose a university based community type program. This has worked beautifully thus far. I think I have a small advantage of seeing the inner workings of both types of programs.

I could not stand the thought of very little OR time in my first 2 years. Although my home program was like this, I saw many of the interns/PGY-2s become somewhat bitter and forgetting why they were going through all the scutwork/crap. Although less bitterness is sure to happen after the 80 hour/week changes, OR time for PGY-1,2s will likely not increase.

At my program, you are in the OR a ton as an intern which is very nice. I've already done a couple of lap choles, lap appys, hernia repairs, mastectomies, etc solo. Every time I finish a case I actually get to do, I'm so pumped and remember why I show up at the hospital at 5am. Luckily, my program has some VA experience and the indigent experience is there . Plus, scutwork is nil.

I do miss the fact that at my home program, the chief resident ran the show. Now, my attendings usually run more of the show (although this varies greatly from attending to attending). I've said on this board before that you should never underestimate autonomy.

It's definitely two different worlds with advantages/disadvantages to both. I'm pretty happy with my current situation simply do to the continuity of care I have with patients. It's great to work a patient up, take them to the OR, and watch them progress post-operatively. I also feel that research opportunities are abound (although usually clinical) and that matching at good fellowships happens most anywhere.

I don't feel at all limited in academics or future fellowships from my current residency. The problem with saying "you can match at a 'better' fellowship if you go to a more prestigious residency", is that most of us who chose not to go to the "more prestigious (academic) residency" do not want a "more prestigious fellowship". I think you need to set your priorities. If you need/want to say I'm in surgery residency at Hopkins, then go. I never felt that need. Some say, if you go to Hopkins then you have a better chance of matching MD Anderson for surg onc. Although, that is likely true, I can't say that every future sur onc fellow wants to be at MD Anderson.

Anyway, I'm rambling (post-call, beat down, rambling ). It's tough to pick the type of program you want and then to pick the exact program you want. I'm glad that decision is over for me. Just go into interviews with your eyes/ears wide open and do not make the mistake of judging a program prior to checking it out (I did that multiple times, and was surprised more than not)

 

[droliver]

Dr. Evil,

what's a "university-based community program" mean?

Just curious...

 

[dr.evil]

University based means that a university/medical school is associated with the residency program while still practicing in mostly for profit/private hospitals. This also usually means that you have 3rd/4th years students in your hospitals, duties with teaching, etc. You also have the advantage of faculty who are academic physicians in a private setting. There are quite a few of these programs out there like Baylor in Dallas (although I'm not sure of it's true affiliation with Baylor or even if it has one. I don't think they actually have 3rd year students), Texas A&M/Scott&White, Univ of Oklahoma-Tulsa, University of Kansas-Wichita, University of North Dakota, Michigan State (As you can tell, I'm from middle America).

This is contrast to simply community based such as Greenville, Good Samaritan, Orlando, Carolinas, etc. They are residency programs unassociated with medical schools which means no med students except for outside sub-I's who rotate through.

At least, that's my take on it. You could call them semi-academic. Granted, these are much more common in Family Practice residencies that surgery.

 

[droliver]

ok..... I would call that a University-based program. Ours works kind of like that. We have a 2 very large trauma services & a busy general surgery service run by the residents @ the university with a smattering of private cases. We have two large private hospitals, a rehab hospital, and a pediatric hospital 1 block down the street that house our attendings private practice cases, our cardiothoracic divison, transplant, peds surg, and some rotations with two large private general & thoracic/vascular groups. There's a VAMC in the suburbs about 10 mins from downtown as well that we run. I think it works pretty well as you spend ~ 2 full years worth cutting your teeth in a private hospital setting while we still have an unusual amount of autonomy (these days) @ the University & VAMC

BTW, Baylor-Dallas is not really university affiliated. It's owned by trustees of the Baptist Health System & formerly was home to Baylor Medical School some time in the past. That being said, it has a wonderful reputation & is probably the top community program in the country. Some of the medical students from Southwestern rotate on services there

 

[dr.evil]

OH. Well I guess that's a good point. I think I make the distinction because we don't have a true "university" hospital. Therefore, we are mostly practicing in a community type setting (except for the VA). At times, it feels very "university" (especially trauma) while other times much more "community". A nice balance I think. We have a surgery service run by residents but it is usually too slow in my opinion. My home program had a rotation to a community hospital during the 4th year but that was about all you got in a private setting.

It sounds like Louisville has a nice setup with a good balance (I just didn't interview there because of the 'malignant' rumors). It sounds like they are mostly rumors and hold little basis in truth according to your experience.

How much time do you guys spend at the VA, University, Private, Children's hospitals? I'm trying to get my program director to let us have a little more time at the VA considering we don't have a university hopsital. Although the bureaucracy sucks, the pathology is endless.

 

[droliver]

let me think..... Here @ my residency http://www.louisvillesurgery.com/

I just finished my chief block @ the VA & I will have spent a total of

- 7.5 months of my five years there @ the VA (6 on service & 1.5 months of endoscopy there). http://www.va.gov/603louisville/

- 3.5 months total @ the children's hospital (a little less than most of my fellow chiefs). http://www.kosairchildrens.com/

- 7.5 months @ the private hospital where our attendings do most of their private practice cases. This is kind of the de-facto University Hospital for private cases & our attendings (b/w general,cardiac, plastics, neurosurgery, orho) do about 90%+ of all the cases booked there. Planned for an NCI designated cancer center to open there next year http://www.nortonhealthcare.com/body.cfm?id=48

- 8.5 months @ the other downtown private hospital (2.5 on transplant, 5 months on the private general service w/ some university private cases, 1 month CV). This was the 6 or 7th busiest cardiac center in the country & where the ABIOCORE artificial heart & the hand-transplant were done FYI. http://www.heart-lung.com/

- 1 month @ a suburban private hospital http://www.caritas.com/

- that leaves ~ 30 months @ the University http://www.uoflhealthcare.org/