3+fellowship vs. 4 year programs

[thirteen78]

Now I'm sure that this has been discussed in much detail, but I didn't see it on the forum...

I've heard a lot of 4 year (both 1-4, and 2-4) say that 4 year programs are the only way to go, and that all 4 year programs will not take a 3yr grad onto their faculty without more experience under their belt.

Conversely, the 3 year programs say that the 4th year is a waste of time since you spend most of it in electives and moonlighting, so why not work in the community and get the big bucks.

The question that no one can really answer....is a 3yr program plus a 1 or 2 year fellowship comparable to a 4 year program if you're looking to go into academics?

Any thoughts anyone?

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[Seaglass]

We have had no trouble placing 3 year grads into academics if that is what they want to do, you have to remember that >3/4 of programs are 3 years. From what I've heard, 3+ fellowship is a pretty powerful combo for going into academics although not required. If you have your heart set on going on faculty at a particular academic program you would be best served by looking online and seeing what kind of training their faculty has.

 

[southerndoc]

Go to the program that you like best.

If you want to have more critical care training and electives, then go to a 4-year program. If you feel you do not need this training, then 3-year programs will probably suffice.

 

[EMResident]

Now I'm sure that this has been discussed in much detail, but I didn't see it on the forum...

I've heard a lot of 4 year (both 1-4, and 2-4) say that 4 year programs are the only way to go, and that all 4 year programs will not take a 3yr grad onto their faculty without more experience under their belt.

Conversely, the 3 year programs say that the 4th year is a waste of time since you spend most of it in electives and moonlighting, so why not work in the community and get the big bucks.

The question that no one can really answer....is a 3yr program plus a 1 or 2 year fellowship comparable to a 4 year program if you're looking to go into academics?

Any thoughts anyone?

It is possible to enter academics regardless of the residency you attend.

If you look at trends among graduates entering fellowships and academics, it turns out that 4-year residency grads actually enter fellowships MORE than 3-year grads. On a "percentage of graduate" basis, 4-year grads tend to enter what we would term "academic" jobs more than their 3-year counterparts.

As a first-year attending, 4-year graduates are -- by definition -- more trained than a 3-year graduate. This is because, obviously, they have had one more year of training. This equals out by about the 2nd or 3rd year as an attending.

Speak with as many 3-year grads and 4-year grads as possible and form your own decisions. Ask for the data behind people's statements, though. Anecdotes are useful, but a shaky foundation on which to build decisions.

 

[FoughtFyr]

Look at the recent paper by Stead, Sadosty, and Decker (here: http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=15860694&query_hl=1 or here: http://www.aemj.org/cgi/content/abstract/12/5/412) that is a "roadmap" to academia. The three versus four year thing is not an issue. Granted, the authors are the leadership of a three year residency (Mayo), but Decker trained at Denver so the four year camp is represented. I think that if you want an academic career and have the acumen for it, you can find it, regardless of where you train (within the U.S. EM system).

- H

 

[southerndoc]

If you look at trends among graduates entering fellowships and academics, it turns out that 4-year residency grads actually enter fellowships MORE than 3-year grads. On a "percentage of graduate" basis, 4-year grads tend to enter what we would term "academic" jobs more than their 3-year counterparts.

I'm sure this is due to 4-year programs taking more people who are interested in academic medicine (probably because those that are interested in academic medicine tend to apply and rank 4-year programs higher).

We have a very high fellowship rate (usually 30-50%) in our 4-year program.

 

[roja]

I think that this is an incredibly tired arguement. There are so few four year program so being able to assess the percentage that go in is difficult. It is *all* pretty much antecedal.

Its really a decision you have to make yourself. If you are considering fellowship, then you should figure out if the extra year is something you want to do.

Fellowship is always more solid than simple residency. Some four year programs won't hire someone who comes straight from a 3 year program. However, after a year of attending, they often do. (kind of nec as there are so few 4 years).

I disagree with the statemtn that a four year grad is more trained than a three year. They have done an extra year but much of it is elective and off service. A more valuable question to ask *ALL* programs is how many months of ED do you do total. You are going to be an ED MD. you want maximum ED exposure.

We have several younger attendings from three year programs. one year out htey are light years ahead of the few four year grads we have in our department. Granted, antecedal again.

Pick a program you like. The rest is all nonsense.

 

[southerndoc]

I disagree with the statemtn that a four year grad is more trained than a three year. They have done an extra year but much of it is elective and off service. A more valuable question to ask *ALL* programs is how many months of ED do you do total. You are going to be an ED MD. you want maximum ED exposure.

Most of the four-year programs offer more electives and more critical care time, which is beneficial in the ED. As a general rule, four-year programs usually have more ED time.

Pick a program you like. The rest is all nonsense.

I couldn't agree more. Find a program you like and go there. If you're undecided between three- and four-year programs, then a four-year program is probably not for you.

Granted, the authors are the leadership of a three year residency (Mayo), but Decker trained at Denver so the four year camp is represented.

Actually the four-year program isn't represented in their article. Denver only became a four-year program this year. In prior years, it was a three-year (2-4) program. It may seem like I'm splitting hairs here, but there is a difference. PGY-2-4 programs generally have an equal amount of ED experience as three-year programs. Also, the PGY-2 and PGY-3 years are spent not in an administrative/junior attending role, whereas with true four-year programs, the third- and fourth-year are usually spent as junior attendings supervising other residents and seeing all patients in the department to further teaching skills and patient exposure.

 

[tonem]

I think the reason places with four year programs won't hire graduates of three year programs right out of residency is because it makes it harder to justify that four years is better. I've also heard that three years of residency plus one year of attending responsibilities is much better than four years of residency...the thing I think that supports this statement is the fact that in-service scores for 3rd year senior residents and 4th year seniors are almost identical.

 

[southerndoc]

I think the reason places with four year programs won't hire graduates of three year programs right out of residency is because it makes it harder to justify that four years is better. I've also heard that three years of residency plus one year of attending responsibilities is much better than four years of residency...the thing I think that supports this statement is the fact that in-service scores for 3rd year senior residents and 4th year seniors are almost identical.

The test is designed for a three-year level. The learning curve between years is going to lessen with each subsequent year (i.e., a fifth-year surgery resident scoring about the same as a fourth-year resident). It doesn't mean that the extra year doesn't provide additional training and make you a better physician.

 

[bartleby]

Yes, but this also reinforces the point that you are sacrificing a tangible of income (>$130,000) for some quite intangible benefits.

The test is designed for a three-year level. The learning curve between years is going to lessen with each subsequent year (i.e., a fifth-year surgery resident scoring about the same as a fourth-year resident).

Definte "better". You can easily make the argument that you are going to learn just as much if not more by working as a true attending than you are in 7-8 months as a 4th year resident. It is somewhat disingenous to sell 4th year residency programs on the basis of these promises which are largely non-quantifiable. It is perfectly reasonable a residency saying that they offer a 4 year program because it is the best way to train an emergency physician, in their opinion. But don't make promises you can neither keep nor prove.

It doesn't mean that the extra year doesn't provide additional training and make you a better physician.

 

[southerndoc]

Definte "better". You can easily make the argument that you are going to learn just as much if not more by working as a true attending than you are in 7-8 months as a 4th year resident. It is somewhat disingenous to sell 4th year residency programs on the basis of these promises which are largely non-quantifiable. It is perfectly reasonable a residency saying that they offer a 4 year program because it is the best way to train an emergency physician, in their opinion. But don't make promises you can neither keep nor prove.

?

I make no promises. As I pointed out earlier, applicants should go to the program that they are most interested in, be it a three- or four-year program.

I think you give false hope by stating that 7-8 months of "attendinghood" is equivalent to the fourth year of residency. While it is true that autonomy can be a good thing, being an attending is not primarily a learning role. There is no supervised teaching like what occurs in the 4th year of residency. By the conclusion that being an attending substitutes for a year of residency, one could probably just forego residency altogether and begin practicing immediately after medical school. He or she would learn the material. It might not be an ideal learning situation, especially for the patients. We have residencies because it's safer to learn under supervision.

 

[roja]

Most of the four-year programs offer more electives and more critical care time, which is beneficial in the ED. As a general rule, four-year programs usually have more ED time.


.

Our program is a 3 year program and we do more ED time than the vast majority of four years. (PD believing that ED training requires ED exposure)

The point being, be familiar with RRC requirements. (there is no min/max number of months, however, more being better). Then assess if the off-service rotations etc fit in with what you believe is important or necessary to your personal training.

(if I remember correctly: 2 months of units {any unit, micu,picu,sicu,ccu}, gas, ortho, l&d, EMS.)

And most importantly, find a program you like and that fits in with your life.

If the arguement that four years puts out better trained MD's, then 85% of graduating ER residents are inadequately trained.

IMO, the truth of ALL the arguements is that you will get good training at both a three and four year program. You just have to find a program that fits with your life.

 

[quideam]

Just jumping in here briefly as a lowly MS2, it seems to me that a lot of the more "hardocre" programs are four year programs (USC, Cook County, Downstate, Lincoln). So in that case, if you wanted to become an "em monster" , wouldn't it be better to go to one of these programs? I mean, for example, USC's curriculum does have 3rd and 4th years running sections of the ED, etc. It seems like a very intense experience you wouldn't get anywhere else.

 

[FoughtFyr]

Just jumping in here briefly as a lowly MS2, it seems to me that a lot of the more "hardocre" programs are four year programs (USC, Cook County, Downstate, Lincoln). So in that case, if you wanted to become an "em monster" , wouldn't it be better to go to one of these programs? I mean, for example, USC's curriculum does have 3rd and 4th years running sections of the ED, etc. It seems like a very intense experience you wouldn't get anywhere else.

Except that, under this logic, 4 year program grads would have better job opportunities, board scores, and would dominate the leadership of the field and that simply isn't so. There are "hard core" programs in the 3 year ranks (e.g., Indiana, UCSF) and at least one of the programs you list above (Cook) is a 2-4 program. That has more to do with billing than training. A second or third year resident in Illinois has a license and Medicare/Medicaid can be directly billed for their services. Hence, in a resource poor ED can't "carry" them (unlicensed, non revenue-generating residents) for one or two years - making them come in with a year under their belts solves the problem... There is a big difference in the 2-4 programs and the 1-4s in that the amount of EM training at a 2-4 is roughly equal to that of a three year program. It is the 1-4s that have a genuine claim to more electives, greater exposure, etc.

Again, as has been said many times and many ways, go where you feel is the "best fit" for you. Realize that there are almost no absolute benefits to a 4 year program other than being hirable by a four year program the day after graduation. That said, if that (being on staff at a four year program) is your goal, or if the length or depth of the four year curriculum feels "right" to you, or even if you just like the geography of a four year program best, then go there. The only "wrong" reason to go to a four year program is a sense that the profession, as a whole, will see you as "better than" (a three year grad) in some regard - because, on the whole, that is simply not the case.

- H

 

[FoughtFyr]

Actually the four-year program isn't represented in their article. Denver only became a four-year program this year. In prior years, it was a three-year (2-4) program. It may seem like I'm splitting hairs here, but there is a difference. PGY-2-4 programs generally have an equal amount of ED experience as three-year programs. Also, the PGY-2 and PGY-3 years are spent not in an administrative/junior attending role, whereas with true four-year programs, the third- and fourth-year are usually spent as junior attendings supervising other residents and seeing all patients in the department to further teaching skills and patient exposure.

O.k., my bad. And I don't think you are splitting hairs. 2-4 programs are really just 3 year programs able to bill for their residents' work earlier in training. To me there is no difference in the training between a 2-4 and a 1-3 (especially if the intern year is not "embedded" in the program's institution).

That said, the article is a good one for the OP's original question. If someone wants into academia, the 3 versus 4 year thing is not really a factor. I do agree with you that more four-year graduates enter academics, but that is likely (as you pointed out) a factor of selection bias. If one is looking to "go academic", they are really signing up for a lifetime of lower pay and very active learning. For those persons, an "extra" year is no great shakes and may, in fact, be attractive. For the "community practice" oriented EP, an extra year is one less year of autonomy and full pay for no real benefit - a poor choice. But an academic career can be started anywhere! I am personally looking at three years plus 2 years of Tox. I imagine that I will do just fine when seeking an academic post. I don't believe that 4 years plus 2 of Tox would have put me at any appreciable benefit.

- H

 

[southerndoc]

If the arguement that four years puts out better trained MD's, then 85% of graduating ER residents are inadequately trained.

I never said that. Additional training in a four year program does not translate into three years of training being inadequate. Not equal does not mean inadequate.

 

[southerndoc]

Since when can you not bill Medicare for unlicensed providers? I know the billing is different for PA's and students, but not for residents. As far as I know, we bill for the full amount if unlicensed residents see patients. This is why we must write "MD" or "Resident" after our names to distinguish us from medical students and PA's for billing purposes.

Considering my state doesn't allow one to get a medical license until after 2 years of residency, there would be a lot of patients who are seen by unlicensed residents who would not get paid.

Attendings do see every patient in the department.

 

[FoughtFyr]

Since when can you not bill Medicare for unlicensed providers? I know the billing is different for PA's and students, but not for residents. As far as I know, we bill for the full amount if unlicensed residents see patients. This is why we must write "MD" or "Resident" after our names to distinguish us from medical students and PA's for billing purposes.

Considering my state doesn't allow one to get a medical license until after 2 years of residency, there would be a lot of patients who are seen by unlicensed residents who would not get paid.

Attendings do see every patient in the department.

You can bill as "incident to" billing for unlicensed providers, assuming that the attending sees the patient and repeats (and charts the repetition of) all critical aspects of the H&P AND signs all of the orders, scripts, etc., much in the same fashion as you would for a medical student. As licensed providers a program can directly bill (except for states that exclude residents by statute such as MN) for the services provided by residents. Given the lower cost to the institution for residents, this can translate to a serious chunk of change.

- H

 

[roja]

I never said that. Additional training in a four year program does not translate into three years of training being inadequate. Not equal does not mean inadequate.

I didn'dt say you did. I was responding to one of many 'points' I have heard made in the past regarding four year programs.


And not equal (or unequal) has definate negative connotations:


un·e·qual ( P ) Pronunciation Key (n-kwl)
adj.
Not the same in any measurable aspect, such as extent or quantity.
Not the same as another in rank or social position.
Consisting of ill-matched opponents: an unequal race.
Having unbalanced sides or parts; asymmetrical.
Not even or consistent; variable.
Not having the required abilities; inadequate: “It was maddening to be unequal to many enterprises” (D.H. Lawrence).
Not fair. See Usage Note at equal.



Probably not what you meant, but by stating that 3 year programs are not equal to 4 year program implies that 3 years are inferior.


I actually interviewed and ranked 3 and 4 years. 3 years were at the top but there was still one or two 4 years that I would have been happy at. And I believe all would have given me good training. Not that I am pursuing a two years fellowship/masters, I am damn glad I am at a 3 year. And I don't feel inadequately or unequally trained at all.

Again, it really becomes a personal decision.

 

[southerndoc]

un·e·qual ( P ) Pronunciation Key (n-kwl)
adj.
Not the same in any measurable aspect, such as extent or quantity.
Not the same as another in rank or social position.
Consisting of ill-matched opponents: an unequal race.
Having unbalanced sides or parts; asymmetrical.
Not even or consistent; variable.
Not having the required abilities; inadequate: “It was maddening to be unequal to many enterprises” (D.H. Lawrence).
Not fair. See Usage Note at equal.

Thanks for the definition. I forgot what unequal meant. I still cannot pronounce it, and your definition didn't provide the proper way to pronounce it. Maybe it's the Southern accent. Alas, I will survive.

Probably not what you meant, but by stating that 3 year programs are not equal to 4 year program implies that 3 years are inferior.

3 does not equal 4, numerically or in training. By saying the two are not equal does not imply inferiority in any reguard. If you feel that unequal means inferior for a three-year program, or that less training means inferior then you should address some insecurity issues. Keep in mind that this refers to quantity only and not quality. Some three-year programs provide better training than some four-year programs. Overall, however, four-year programs provide better experiences and training through more critical care time and ED exposure.

Regarding requirement of four-year residencies for academics, there is an advertisement in the SAEM newsletter for an attending position that states that four years of residency is required. That's the first time I've seen that. I wonder if more programs, especially four-year programs will follow.

 

[Apollyon]

Regarding requirement of four-year residencies for academics, there is an advertisement in the SAEM newsletter for an attending position that states that four years of residency is required. That's the first time I've seen that. I wonder if more programs, especially four-year programs will follow.

I saw that too, for the Harvard program. Interestingly, I've done 4 years of residency (with my prelim year), even though the program I'm at is 3 years.

It's academic anywhow (forgive the pun) - as Groucho said, "I would not join any organization that would have me as a member".

 

[southerndoc]

I saw that too, for the Harvard program. Interestingly, I've done 4 years of residency (with my prelim year), even though the program I'm at is 3 years.

It's academic anywhow (forgive the pun) - as Groucho said, "I would not join any organization that would have me as a member".

That's the first time I've seen an advertisement such as that. I wonder if the other four-year programs will follow suit?

We have a couple faculty positions available (due to more funding allowing more faculty members). Although our chief prefers four-year graduates, she said she won't exclude three-year graduates if they have a solid CV with adequate research experience or they've done a fellowship.

 

[FoughtFyr]

We have a couple faculty positions available (due to more funding allowing more faculty members). Although our chief prefers four-year graduates, she said she won't exclude three-year graduates if they have a solid CV with adequate research experience or they've done a fellowship.

Yeah, but the Harvard ad wanted four years AND fellowship. That would exclude most of the current leaders in the profession. There was no "consummate experience" disclaimer, but I have to think if an experienced professor wanted to work there, they would allow it. I think that was an ad targeting new grads. But I could be wrong...

- H

 

[WilcoWorld]

I certainly agree that inequality does not necessarily imply that one of the compared entities is inferior to another. When I say that apples are not equal to oranges I'm not implying that one is better than the other.

However, you wrote "Overall, however, four-year programs provide better experiences and training through more critical care time and ED exposure."

So noone need infer what you are implying here, you explicitly stated your opinion.

 

[roja]

I certainly agree that inequality does not necessarily imply that one of the compared entities is inferior to another. When I say that apples are not equal to oranges I'm not implying that one is better than the other.

However, you wrote "Overall, however, four-year programs provide better experiences and training through more critical care time and ED exposure."

So noone need infer what you are implying here, you explicitly stated your opinion.

It does seem rather obvious.

Southerndoc
Your rather inacurate assumption that I am insecure is ridiculous and seems more to reflect your own bias. The defenition is appropriate. Your insinuations are not.

 

[southerndoc]

However, you wrote "Overall, however, four-year programs provide better experiences and training through more critical care time and ED exposure."

Fine, so I said it in a different sentence. You can quote me on that sentence, but do not quote my sentence of unequal meaning inferior.

Regarding me being insecure, I am where I wanted to be: in a four-year program with excellent research opportunities. I have been pretty much set on a four-year program since in medical school, and actually began looking into my program before I even enrolled in medical school. I plan a career in academics (part-time), including performing a fellowship. I would rather be in a position to have my training help me or have no influence as opposed to hurt me. Nobody will ever say "he graduated from a four-year program, he's not qualified." However, as my recent SAEM post pointed out, the same cannot be said of three-year graduates.

 

[bartleby]

Well, why not five years instead of four? You'd certainly be better off with another year of residency, right?

Residency could be ten years long, but the first day you're out on your own you could run into something you'd never seen as a resident.

Graduate medical education is a foundation to help you deal with the experiences to come. Actually functioning as a decent modern physician is a far more complex matter. The sand shifts beneath your feet every day. When I started med school the fact that estrogen replacement therapy was iron clad prevention against coronary artery disease was taken as gospel. Now? The fact that it's washed up is already old hat.

I think you give false hope by stating that 7-8 months of "attendinghood" is equivalent to the fourth year of residency. While it is true that autonomy can be a good thing, being an attending is not primarily a learning role. There is no supervised teaching like what occurs in the 4th year of residency. By the conclusion that being an attending substitutes for a year of residency, one could probably just forego residency altogether and begin practicing immediately after medical school. He or she would learn the material. It might not be an ideal learning situation, especially for the patients. We have residencies because it's safer to learn under supervision.

 

[southerndoc]

Well, why not five years instead of four? You'd certainly be better off with another year of residency, right?

Residency could be ten years long, but the first day you're out on your own you could run into something you'd never seen as a resident.

Graduate medical education is a foundation to help you deal with the experiences to come. Actually functioning as a decent modern physician is a far more complex matter. The sand shifts beneath your feet every day. When I started med school the fact that estrogen replacement therapy was iron clad prevention against coronary artery disease was taken as gospel. Now? The fact that it's washed up is already old hat.

I fail to see what HRT has to do with length of residency training.

As more advances occur in medicine, residencies will get longer. There is discussion of making internal medicine a four-year residency. Probably in twenty years time this will be the case... perhaps in only ten.

Why not cut surgery residencies to three years?

Here's the bottom line: Those that do four-year residencies will almost always say that the fourth year is invaluable and four years of training is the way to go. Those that do three-year residencies will almost always say that the fourth year is a $150,000 mistake and doesn't offer anything. Having never had that fourth year of training, I will take the advice of the four year program graduates.

As I told someone in a PM, this is the last post I am making in this thread. If, however, after my last year of residency I feel that the additional year was a complete waste, then I will search for this thread and be the first to post my opinion.

See you all on the other threads.

 

[FoughtFyr]

in a four-year program with excellent research opportunities. I have been pretty much set on a four-year program since in medical school, and actually began looking into my program before I even enrolled in medical school. I plan a career in academics (part-time), including performing a fellowship. I would rather be in a position to have my training help me or have no influence as opposed to hurt me. Nobody will ever say "he graduated from a four-year program, he's not qualified." However, as my recent SAEM post pointed out, the same cannot be said of three-year graduates.

To applicants on this board, while Southerndoc is right (in that he is where he wants to be) please do not read into his post that research (should that be your interest) is not available elsewhere. I am in a three year program and had invited conference presentations, abstracts, book chapters and papers, all in my intern year (as did many of my classmates). There are STRONG research opportunities in some three year programs.

- H

 

[The White Coat Investor]

Just jumping in here briefly as a lowly MS2, it seems to me that a lot of the more "hardocre" programs are four year programs (USC, Cook County, Downstate, Lincoln). So in that case, if you wanted to become an "em monster" , wouldn't it be better to go to one of these programs? I mean, for example, USC's curriculum does have 3rd and 4th years running sections of the ED, etc. It seems like a very intense experience you wouldn't get anywhere else.

If your main goal is to be a hard core EM monster......yea, I think those county places you mention will allow you to become that.... I like it...I'm going to let my patients today know I'm one hard core monster...so they better watch out!

 

[quideam]

LOL.... I just used that term because i've heard it elsewhere (from some SDNers perhaps??)... hehe

In any case, the reason I brought that up is because i'm interested in doing international EM (disaster response, etc), and I feel like if i'm going to be in a situation where i'm the only doctor caring for hundreds of sick/injured patients, that I should know as much as possible - medically, surgically, etc. So to me, it may be worth spending an extra year as a resident in order to train at a really "hardcore" county place like Cook or USC so that I can have the extra skills/knowledge you can only get in crazy places like that.

Oh, and I want to have "EM Monster" stitched on my labcoat.

Q

 

[roja]

Nobody will ever say "he graduated from a four-year program, he's not qualified." However, as my recent SAEM post pointed out, the same cannot be said of three-year graduates.

Ah yes, because 85% of EM graduates are not qualified.





The reason many places won't hire a 3 year graduate STRAIGHT out is that there is a precieved awkwardness. That a PGY-4, although not equally as trained, might find it odd to present to a 3 year grad. HOWEVER, a 4 year PGY4 is not equal to a 3 year grad. Its the amount of ED time that determines this.

Given the brevity of 4 year programs (many of which will hire 3 year grads after one year of attending), the arguement that it sets you in a better position, doesn't hold alot of water.

A very definiate advantage of a four year program, is significantly more elective time. If this is something you desire. If I wanted to do significant international travel, etc, then a four year would definately be an advantage. (although we have residents who have gone to both africa and thailand). It may give you more dedicated research time.

However, I tend to agree with my PD: people who want to do research, do research. No matter what.


I have done extensive research, have written 3 chapters for a book, and have been eligable to sit for the RDMS (ultrasound) since half way through my 2nd year. And I am not really an exception in my program.

While a four year program doesn't harm you, the converse of that statement is not necessarily true, that a three year program does.

So, as has been reiterated, ad nauseum, its really a personal decision. The 3 vs 4 arguement can really be boiled down to what program fits you. If you are like southerndoc and have wanted to be in a four year since conception, then a four year is where you should go. If you are a die hard 3 year, you should only apply to three. If you don't really care, you should apply to both and figure out which programs you like the best.