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Discussion in 'Emergency Medicine' started by The White Coat Investor, Apr 1, 2004.
I'm curious about this.
I hesitated and almost clicked on both 3 and 4, but then I remembered me thinking I would rather scrambled into a spot than go to the one four year program I interviewed at.
I had a couple 4 year interviews set up, but I canceled them once I saw how good the 3 year places I interviewed at were. But to be fair the 4 year places were not of Dever or Cinci quality. The thought of doing a prelim year is horrible to me though and the 4 year program would have to be leaps and bounds better than a 3 year place for me to have ranked it higher.
Like I said before, I ranked several 4 year programs at the top of my list above some very good 3 year programs. Although among the mediocre programs, I'd rather go to a 3 year over a 4 year.
I guess I'd rather get as much training as I can from fantastic programs like Denver and Highland. At the same time, If I'm training somewhere crappy, I'd be dying to jump ship ASAP.
I interviewed at both and did AI's at a 3yr and a 4 yr programs.
I thoght the level of confidence that a 4th year had was great and decided that I would not mind feeling like that come time to find a job and be on my own. As a medical student, working with a 4th year resident was great, it was just like working with an attending.
Also, since I have an interest in Peds EM a lot of the 4 yr programs offered more peds electives or a "minni Fellowship."
As for the whole "$150,000 mistake", I'll let you know in 4 years-
I think that is exactly the point.
Long time lurker, first time poster (actually think I know some of you)
4 years are definately better if you are interested in academics. Easier to get both academic jobs and fellowships. There are lots of great fellowships based at 4 year training sites that strongly prefer to take graduates from 4 year programs because its just not right to have graduates 3 years out of med school in positions above residents with generally the same amount of clinical experience.
I'm not sure if I want to do community or academics, so 4 year programs are pretty attractive to me. Its just better to keep all my options open for now. I don't want to make a decision based on one year and then have 20 years of unfulfilled expectations and regret.
Think about it, graduating from Cinci or Denver and doing a fellowship at Highland or Bellevue... how do you spell P.I.M.P.?
When I was all done with interviews it turned out my top choices were all 4 year programs ([email protected] [email protected]) and I hated the one 3 year program I interviewed at. I didn't hate it because it was a three year program but because of some real jerks I met while I was there. I ended up only ranking the 4 programs I liked because I figured being somewhere I like was more important than being somewhere for only 3 years
There aren't very many competative fellowships in EM. I don't know the exact numbers but probably 90% of graduates don't fellowship, and more than 50% of academic EM attendings never fellowship. Sure, it may be tough to get Tox at Bellevue, but I think that's about it.
I think a 4 yr program would be more important if you DIDN'T fellowship in order to secure an academic position. If you do 4 yrs then fellowship you're talking up to 6 years after graduation, which isn't really necessary IMHO.
True that a 4 year program is a good bargain if you really don't want to do a fellowship afterwards. You will definately feel more comfortable clinically after 4 years of training than 3 years.
My point was just that doing a 4 year program expands your options for fellowships if you really want to do one. I have a friend that is a 3rd year resident at a very respected 3-year program. Was applying to ultrasound fellowships this year and wanted to go to a great program based at a well-known 4-year residency by the ocean. All of her family lived in this city and she really wanted the location. However, she was told that they were only interested in taking a graduate from a 4-year program (which they did). Anyways, she's gonna be at a great ultrasound fellowship at a 3-year program in a different time-zone. Everything worked out, but it just wasn't her top choice as far as location. So basically there are still a whole lot of fellowship options for grads for 3-year programs...but more for 4-year grads.
I ranked both but the few 4 years were dead last (except one).
In the end, didn't matter...
I don't think you understood the point I was making. I want to be rock solid with as few doubts as possible at the end of my residency and that is exactly what these residents were. Opposed to the third years which had to rely on attendings more.
The fourth years had confidence and were able to field my questions, teach and felt VERY comfortable, that comfort level and confidence are not always there in the 3rd year of training.
That being said I applied to both and went with my gut and asked the question "When I am running an ED which residents do I want to be like?"
i actually have to disagree with your point. there are 100 3 year programs and 32 4 year programs (including 2-4, 1-4). if you look at the scores of inservice exams, there is very little difference between 3rd and 4th year residents.
you also point out that as a med student, working with a pgy-4 was like an attending. i think the reason that a pgy-3 seems less like an attending (maybe in terms of teaching they gave you, attention they gave you, etc) is two fold. one, 3 year programs tend to be less academic. as a result, it may simply be preference -- most residents would rather see patients than teach a med student. secondly, most 4 year programs structure it so that the pgy-4 runs a half of the er (aka cheap attending). as a result, they have more time to teach and are expected to teach and are not responsible in moving patients (as they rely on the pgy-2,3 in the ed). in a lot of programs, the third year is expected to "move the meat" and keep the flow of the er running well while the attending is tied down with interns, residents, etc. i think those reasons are why the 4th year feels more like an attending. i feel it is time constraints not lack of training that makes a 3rd year seem perhaps less attending like in the er.
there may be some truth in your statement -- i'm sure an extra year of having someone else be liable for your decisions helps. but c'mon there are graduates of 100 programs that only did 3 years of training. i'm sure an extra year only helps in terms of knowledge but as you alluded to it is sometimes refered to as the "150,000 mistake" and that's probably being conservative. if you have loans, it's one more year of not being able to pay them back. plus, there's interest on the money you make, etc, etc...
I think this decision becomes much more important if you are thinking about academics. True, there are good 3-year academic programs (UC-Davis), but the heavyweights like Cinci and Denver are still 4-years. Everything you said about academic posts and getting fellowships at 4-year programs is legitimate as well.
Of course you can do a 3-year residency, work for 1-year, and then get an academic position or fellowship at a 4-year program. But that seems to me like its just getting complicated.
To each their own. If you just want to practice in the community and start paying off your loans, then a 3-year program is perfectly fine.
However, if you would like to go into research and teaching or want to be the next Rosen, then there is a shorter list of very academic, reputable programs that would fit for you. And many of these are 4-years.
As far as the $150,000 mistake. If you look at it that way, academics would be a mistake in general as academic EM docs don't generally make as much as the community guys. Obviously there has to be some other motivation.
I'm having trouble following your thoughts here...
I would expect residents in both 3- and 4-year programs to have similar scores on the inservice exam at the PGY-1, PGY-2, and PGY-3 levels. They are, afterall, at the same level. Are you saying that PGY-3 scores are comparable to PGY-4 scores as well?
What if you had a graduate of the 3-year program to take the test after a year of practicing? Would it be comparable to the PGY-4?
The better determinant of how comparable the training programs are would be to investigate their board certification pass rates on the first attempt.
Everyone has their opinions of a 3- v. 4-year program. It's really about personal interest and that's it. Personally, I don't mind losing a year of large income so I can have an extra year to brush up my skills (in clinical medicine and teaching). Out of my top 4 choices, only one of them was a 3-year program. It's just individual taste.
that's what i'm saying. i actually think that the first time pass rate is comparable as well but don't have numbers to prove it. i did have the inservice scores from last year but have mislocated them. but yes, the pgy-3 scores were very similar to the pgy-4 scores.
anyhow, you're right it's personal preference. i think your mind may change as you go through residency. when i ranked programs, 3 of my top 5 were 4 year programs. now, i'm grateful to be at a three year program and would only advocate 3 year programs.
so when i find the inservice reports, i'll post it.
all right --
here are the stats from the 2003 inservice
EM year Mean Median Std Dev Min Max Count
1/ 68.63 / 69 /7.64/ 44/ 88/1269
2 /75.10 / 76 /7.07/ 45/ 92/1215
3 /79.02 / 79 /6.22/ 52/ 96/1143
4 /79.45 / 80 /5.29/ 62/ 92/133
Interesting. There appears to be no real benefit of the PGY-3 year as well (yes, I am being serious).
At any rate, it goes back to my original post: it all boils down to personal preference. You should try to match at a program where you will be happy. You must like the city/area, the residents, the faculty, and the general feeling of the program.
Let?s not kid ourselves here. Who in their right mind is going to go back to being a peon after a year of making attendings? wages? Of course we all know the one or two cases who have done so... but for the vast majority of us once the money starts rolling in and we can start paying back debts we aren?t going to go backwards and will somehow rationalize how the fellowship isn?t really all that important.
And, not to harp on the point that?s already been made, but multiple PDs of 4-year programs have told me that they?d never take a grad of a 3 year program directly as either a fellow or faculty for the reason that OhioInTheWest pointed out earlier.
Geek Medic?s last point is also valid... look at the SDs and you?ll see that the 2nd and 3rd years are comparable. So, jazz, if the sole basis for judging an extra year is the inservice exam then you should actually be pointing out that all programs should be 2 years, not 3.
The main reason I?ll be at a 4 is that I fell in love with multiple aspects of the program. If I had found all of this in a 3 year (and Pitt came damn close) I would have ranked them higher. I don?t think that the 3 vs 4 decision should be all that high on an applicant?s list of priorities unless there?s some reason to make it so (MUCH older applicant, a spouse in a 3-year residency so that both can move together, etc...).
Just my $.02
Umm, that's not what I learned in statistics. The means from 2-3 are statistically different. The means from 3-4 are probably statistically different. Does that matter in terms of ability to practice? In the world of 4 year EM the answer is yes, in the world of 3 year EM the answer is no. A better comparison would be board passage rates or malpractice claims which, at least in my research, were comparable. I'll have to see if I still have that stuff around.
Well, I suppose that would be imprtant if you wanted to go into academic EM, which 90% of graduating EP's don't, and only if you were devoted to going on faculty at a 4 year program, which only represents 25% of programs.
As far as Geek Medic's feeling that he needs to be as comfortable as possible by graduation, that's fine for him. I feel like the 3rd year seniors I worked with were very comfortable, probably because they had seen more ED time due to the time efficiency of a 3 year program. I also realize that the comfort you feel as a graduating senior is nothing compared to having several years of practicing under your belt.
Last, I still feel like a fourth year is better spent in a fellowship adding something extra to your CV than just finishing a residency. Most fellowships are still at 3 year programs, most are not that competitive, and most will be available to 3-year graduates.
3-years is enough. 4 years is fine if that's what you want or you have interests that take up extra elective time, but it's not inherently better. I admit that it makes you more competitive for faculty positions or fellowships at 4-year programs, but remember these are the minority and their market share is shrinking. I am told by graduating seniors (at 3-year programs) and faculty that they have to trouble landing their choice of jobs due to 3 years.
Last, let's throw moonlighting into the mix. If you need to be as "polished" as possible to run an ED will you avoid moonlighting? I am told by graduating seniors that some jobs require some moonlighting experience during residency to prove you can run an ED on your own.
I'm undecided on moonlighting. Here's why:
1. I've been told by a couple respectable faculty members that moonlighting in the ED is not a good idea. EM residents should moonlight outside their specialty. If they are sued while moonlighting in the ED, the chances of them getting malpractice coverage and getting a job as an EP is decreased. Malpractice insurers somehow view practicing and being sued outside your specialty differently than being sued within your specialty.
2. If we are to insist that emergency medicine is a true specialty, then we need to really limit the amount of moonlighting. How many surgery residents moonlight covering call for a surgeon? Not that many (yes, I am aware that it happens). How many internal medicine residents cover call for an internist? How many family practitioners open up their own clinic and "moonlight" on the side doing that? There are two residencies that moonlight frequently: emergency medicine and radiology. It's funny that we allow people outside our specialty to moonlight in the ED. I've even known of a pathology resident moonlighting in an ED!
3. My views may change when I become a PGY-2, 3 or 4 and realize I can make $100/hour moonlighting in an ED somewhere!
As you can see, I have mixed feelings on the issue.
Moonlighting aside, we?re rehashing arguments that have been made for the last decade. It?s kind of interesting that, a whole 2 weeks after match day, we?ve become proponents of whichever kind of program we matched at.
cg, i PMd you about the stats...
Personally, I?m a huge fan ?o moonlighting. But that?s mostly because i have crazy loans to pay back and i wouldn?t mind making an extra grand after taxes working one extra 12 hour a month.
BTW, I completely agree that 3 years is enough. Duke has a 3 year program and not only are the residents rock solid but i?d put our attendings who trained at 3 year programs up against any in the country. BUT, I plan to hard-core academic and just feel that more doors are going to be open to me coming out of a four year program.
Oh, and I checked... this debate has been run exactly 163 times on this board.
Maybe this debate is just something everyone has to do once, you know--kinda like meconium.
Sadly, I?ve done meconium a bunch of times. Only once, however, was it my own.