Having rotated through 2 community programs, 2 academic programs, and having talked to residents or attendings from probably >50 programs in my travels from all sorts of programs (either by interviewing there, having their residents interview at my fellowship program, or having their students come to my residency program, or talking with people at meetings), I have to reinforce that either type program can provide amazing training or crummy training. The attending and resident culture can make or break a program.
I've seen community programs that graduate people with dozens of whipples. I've seen at least one community program where they each did >100 lap choles and that constitutes >10% of their case loads. I've seen academic programs with some rotations that the attendings are nearly absent in some settings (e.g. VA's and "ward services") to ones where the chief better call the attending to blow his/her nose. Sometimes those are even in the same program. I remember rotating with a community surgeon who didn't let you even touch the knife on a carotid because he was so worried about complications, but the same surgeon let you do a open AAA basically skin to skin with minimal assistance.
Common threads that mark high quality programs:
Enough operating, but not too overwhelming so you don't have time to read and focus on cases (I'd say between 850-1200 cases is the sweet spot): I find that programs that are county based (often considered to be academic) and those that are at very busy community hospitals tend to suffer from too many cases. Some academic centers, however, suffer from too few cases (this is not as often the case in community based programs, as they tend to have fewer residents and fewer non-operative rotations in my experience), however exceptions abound. I've seen operative intern case loads at academic hospitals vary from as low as 60 to as high as 200, sometimes even in the same program as luck of the draw definitely plays a part.
Operating on the right type of cases: You need a program that provides a mix of low intensity and high intensity cases. The median number of whipples that people graduated used to be 0 or 1, that has risen now slightly, but it still makes the point. You want to be able to do high end cases so you can bail yourself out of problems when they arise. Higher end academic programs tend to have higher numbers of "tough" cases like liver resections, pancreatic resections, sarcoma resections, etc. but I have seen some select community programs that have tons of these floating around and some academic programs that don't. The common thread for those that do, is that the hospital tend to be the "big dog" of their neighborhood. Those that don't have to refer patients out and have patients referred to them, tend to accumulate the tough cases. Having been on the receiving end of patient transfers from places that have residents, I know it is frustrating for them to have to send the good case to the University hospital, but they don't have staff that can do it with them. When they are done, they will have to do the same thing because they never learned how to do those cases
Good case variety: You might think that doing little cases over and over again is worthwhile, and it is, but not at the detriment of losing the big cases. Doing 100 lap choles can be fun, but it is more nerve wracking if you know that you can't do a hepatico-jejunostomy if needed. For the interns, it is analogous to when you start doing central lines, before you really feel comfortable putting a chest tube in. I know that I definitely relaxed more when I knew I could fix the potential complications without having to call for help. Also, bigger non-inbred programs tend to give you multiple ways to do the same thing (the bigger toolbox as it were). I have noticed recently that in some programs, the residents only learn one way of doing things, which means if that way fails... watch out. In talking with residents, the art of sewing seems to be declining nationwide as stapled anastomoses/advanced energy devices such as the harmonic scalpel and ligasure become more commonplace. Most residents now will never do a tissue repair for inguinal hernia, although being able to do one is essential for contaminated strangulated hernias. It's nice to have someone who is "old school" at your program that forces you to learn these techniques. This can occur in both community and academic settings.
Graduated autonomy for the residents. In our very academic residency it was not uncommon for our 2nd and 3rd year resident to take an intern through a hernia or a chief take a junior resident (2nd or 3rd yr) through a colon with the attending either sitting in the corner of the room or holding retractors when at the VA. As a 4th yr on Trauma, you would often take 2nd years through burn cases and trach/G-tubes and lap choles. I would do endoscopies and minor procedures (seb. cysts/ lipomas/ etc.) totally solo (e.g. not even sure who to assign in my case log) as a 2nd or 3rd year not uncommonly. These teaching cases and solo cases are going away though in no small part due to the work hour restrictions and increasing mandates by the government for attendings to be present for cases. I think this has higher potential to occur in academic settings, and private attendings tend to be more "attached" to their patients, so they are less willing to step back. However, some of the most retentive surgeons I've ever met have been at academic programs, so take that for what you will. You don't want to be by yourself before you are ready, but you don't want someone breathing down your neck once you are.
A focus on keeping up with the latest developments: Here I think academic programs have the opportunity to shine on the patient management and work-up side since the attendings tend to be more up to date with guidelines. This has to be balanced with the fact that new procedures/technologies that pay well or provide an advertising advantage (e.g. mammosite/ultrasound in breast, laparoscopic surgery in GI) seem to spread faster to clinically focused programs. On the other hand, one of my partners who was giving grand rounds at a community hospital actually recently had an argument with an attending at that hospital who claimed that core needle biopsies of breast lesions were never needed and they should all go to excisional biopsy right away.
In summary, look for the things above and don't get hung up on whether the hospital is called a university hospital and in general you won't go wrong. Obviously if you want to be an attending at Hopkins, you are going to have a hard time getting that job from podunk community hospital without passing through a great fellowship, but if you are just thinking about education alone, it's the place, not the name that makes it the right program for you.
