Anybody get the impression that all the "top" IM programs include the majority of inpatient training in tertiary based referral centers? Do you think that this ideal for training? It seems some programs (i.e. UCLA/Stanford) offer a couple months at County/VA hospitals, but still focus the training in the tertiary care universitiy hospitals. In one respect I think that these places are filled with insane pathology with very sick patients with multiple problems, hence offering a great learning experience. However on the other hand, I wonder if tertiary care training is deficient on learning experiences with "bread and butter" medicine and first time diagnostic skills. Just curious what others think on this matter.