Preface: Just one man’s opinion and there are some generalizations, but I think it’s applicable to most programs.
Congratulations, you’ve interviewed at multiple radiology residency programs and now it’s time to make your rank list. How should you rank or sort the list to get the best medical training possible?
Overall, you’ll end up just fine wherever you go and there’s not too many differences between most programs. There are definitely the DO NOT attend radiology residencies where the residents are scutted out, teaching is few and far between, people are generally unhappy and you’re really just a warm body to work long hours (i.e. a malignant program). But those programs are few and I will not name names in this post. The only big difference between most programs is Academic vs Community/Private Practice (PP). And when I say “Community”, it does not carry a negative connotation like a community college. Community just means that it may not be affiliated with a “Universtiy of” or is a conglomeration of multiple private hospitals. There are many phenomenal Community/PP programs that would crush big name Academic places in terms of case volume, diversity, studies performed, and even research.
Academic Programs:
Pros:
- They have name recognition, which makes them competitive and will open a lot of doors for you when applying to fellowship or jobs. Having those names on your resume looks attractive and there’s a good network in place to help lift you to where you are trying to go.
- They have ample research opportunities and you can get published many times over the course of your residency. Even if you don’t like research (most people don’t), you will still have to do some to pad that CV for fellowship and beyond.
- They do high-end radiology with diverse pathology and complex cases. You will see some rare birds and perform slick, cutting edge radiology (IR) procedures that most programs are not set up for. Your imaging is also very high-end with the latest tech and protocols. You will see and do things in these programs that most residents just read about in books.
Cons:
- You don’t actually do that much work as a resident. As a resident, you will be one of many with a long line of people above you on the totem pole, from 30 other residents, 20 fellows, and junior faculty. Most of these big academic programs are Fellow-run and there’s always someone ahead of you taking the good cases and procedures even if you’re a senior resident. A good number of people from academic programs are babied so much that when they get out into the real world, they cannot keep up with PP volume and are forced to go back into academics where volumes are low. The workload of a resident from a big time academic institution is much lower than for a Resident-run PP/Community program. This is particularly true if you’re interested in IR (I know, there’s an IR track now so this is not as big of a deal as it used to be). The fellows at these programs do EVERYTHING except basic PICCs and Ports. Good luck being well-trained going into fellowship if you’ve never done anything besides Thora’s, Para’s, PICCs, and Ports. The same theory can be applied to diagnostic imaging although on a lesser scale compared to IR.
- What you gain in diverse and complex pathology, you lose in speed and efficiency. This is similar to the first Con, because you don’t do as much work as a PP resident. While you will be able to take your time at an academic program and come up with a 10 list long differential diagnosis or be able to spot a rare diagnosis (Zebra), this is not the real world. In the real world, there are hundreds or thousdands more normal or common pathologies than Zebras. And not being able to keep up with volume is a common reason to be let go in the private practice world. For example, I once worked at an academic program where there were 3 radiologists who split 15 MRIs and 200 Xrays per day between them, and if someone added on an MRI or two, they would freak out. Contrast that to an average PP job (PP jobs are still the majority compared to Academic) where you will be expected to read ~30-40 MRIs and ~50 X-rays per day.
- You are more at risk of becoming inbred at an academic center. Academic centers often recruit internally. So many of their staff are former residents and/or fellows (lifers). This is not true with PP/Community. So at an academic center, everyone conforms to groupthink and has one knowledge base/a similar set of experiences to rely on. This can lead to a narrowed lens of which you will see things through. PP has many people from many different programs, each of which uses different words, dictation styles, and techniques for performing procedures. In a PP program, you learn many different ways to skin the cat and learn a little from each of them. In academics, there are much fewer ways of doing things because chances are, one of your attendings trained 2-3 of your other attendings (not very diverse).
PP/Community:
Pros:
- You will get very fast and very efficient with your bread and butter radiology diagnoses and procedures (~95% of your work). This is because there are typically no fellows above you and you are often the only trainee on the rotation at any given time. That means that you run the show starting day 1. It is daunting and there is a lot of trial-by-fire, but you will come out the other end fearless, well trained, efficient, and practical. It can be devastating to your ego if you’re not used to getting things wrong, are shy/indecisive or don’t take criticism well. But if you persevere, you will often come out better prepared for the real world than most academic residents.
- No fellows. I cannot overstate this enough. If there are no fellows above you, then you will learn and screw up at an exponentially higher rate than someone who is in a larger program. You CANNOT be a fly on a wall in a PP/Community program as they are typically smaller and usually 100% Resident-run. In an academic program, if you want, you can hide, dodge work and be lazy because the program is not counting on you and there are multiple layers of protection above you. In a PP/Community program, if you miss something, there are real and immediate consequences. If you are not performing well, not producing volume, or are lazy, you cannot hide and there will be conversations with your Program Director to follow. If you don’t work hard, there will be conversations with your Program Director. In short, you are the first line and often have minimal back up, so get ready to work hard and take responsibility much sooner than you want. The layers of protection (people above you) are a double edged sword because they can help shelter you from being dangerous but can also protect you too much so that you don’t grow as a resident until you graduate, real life hits, and there’s no attending or fellow to back you up – get ready for a rough 1st yr of attendinghood.
Cons:
- You may have a harder time getting into a prestigious fellowship. Name recognition matters and even though a small program in Wyoming or Maine may produce better residents than a University of, the bias is there and your application may go by the wayside regardless of talent.
- There are less research opportunities. I know, you hate research (most people do), but you still need it to pad that CV for fellowship and beyond. In academics, attendings are constantly badgering you to do research with them. Not the case in PP/Community. You often have to initiate.
- You may not see as many Zebras as you would in an academic program. And while 99% of the time you’ll be right in diagnosing the common thing as common, you will get burned when that Zebra pops up and you misdiagnose it. For example, appendicitis is common. But sometimes the appendix is enlarged because of a mucocele, not because it is obstructed/inflamed. If the surgeon goes in and spills just a few of those mucinous cells into the peritoneum, the patient will forever be doomed with pseudomyxoma peritonei. It is devastating for the patient and could have been prevented with a better radiology read. The routine things can be worked up at your PP/Community hospital, but a rare bird is better served at a large tertiary care center such as University of. You may have to read books on these instead of getting first-hand experience.
Congratulations, you’ve interviewed at multiple radiology residency programs and now it’s time to make your rank list. How should you rank or sort the list to get the best medical training possible?
Overall, you’ll end up just fine wherever you go and there’s not too many differences between most programs. There are definitely the DO NOT attend radiology residencies where the residents are scutted out, teaching is few and far between, people are generally unhappy and you’re really just a warm body to work long hours (i.e. a malignant program). But those programs are few and I will not name names in this post. The only big difference between most programs is Academic vs Community/Private Practice (PP). And when I say “Community”, it does not carry a negative connotation like a community college. Community just means that it may not be affiliated with a “Universtiy of” or is a conglomeration of multiple private hospitals. There are many phenomenal Community/PP programs that would crush big name Academic places in terms of case volume, diversity, studies performed, and even research.
Academic Programs:
Pros:
- They have name recognition, which makes them competitive and will open a lot of doors for you when applying to fellowship or jobs. Having those names on your resume looks attractive and there’s a good network in place to help lift you to where you are trying to go.
- They have ample research opportunities and you can get published many times over the course of your residency. Even if you don’t like research (most people don’t), you will still have to do some to pad that CV for fellowship and beyond.
- They do high-end radiology with diverse pathology and complex cases. You will see some rare birds and perform slick, cutting edge radiology (IR) procedures that most programs are not set up for. Your imaging is also very high-end with the latest tech and protocols. You will see and do things in these programs that most residents just read about in books.
Cons:
- You don’t actually do that much work as a resident. As a resident, you will be one of many with a long line of people above you on the totem pole, from 30 other residents, 20 fellows, and junior faculty. Most of these big academic programs are Fellow-run and there’s always someone ahead of you taking the good cases and procedures even if you’re a senior resident. A good number of people from academic programs are babied so much that when they get out into the real world, they cannot keep up with PP volume and are forced to go back into academics where volumes are low. The workload of a resident from a big time academic institution is much lower than for a Resident-run PP/Community program. This is particularly true if you’re interested in IR (I know, there’s an IR track now so this is not as big of a deal as it used to be). The fellows at these programs do EVERYTHING except basic PICCs and Ports. Good luck being well-trained going into fellowship if you’ve never done anything besides Thora’s, Para’s, PICCs, and Ports. The same theory can be applied to diagnostic imaging although on a lesser scale compared to IR.
- What you gain in diverse and complex pathology, you lose in speed and efficiency. This is similar to the first Con, because you don’t do as much work as a PP resident. While you will be able to take your time at an academic program and come up with a 10 list long differential diagnosis or be able to spot a rare diagnosis (Zebra), this is not the real world. In the real world, there are hundreds or thousdands more normal or common pathologies than Zebras. And not being able to keep up with volume is a common reason to be let go in the private practice world. For example, I once worked at an academic program where there were 3 radiologists who split 15 MRIs and 200 Xrays per day between them, and if someone added on an MRI or two, they would freak out. Contrast that to an average PP job (PP jobs are still the majority compared to Academic) where you will be expected to read ~30-40 MRIs and ~50 X-rays per day.
- You are more at risk of becoming inbred at an academic center. Academic centers often recruit internally. So many of their staff are former residents and/or fellows (lifers). This is not true with PP/Community. So at an academic center, everyone conforms to groupthink and has one knowledge base/a similar set of experiences to rely on. This can lead to a narrowed lens of which you will see things through. PP has many people from many different programs, each of which uses different words, dictation styles, and techniques for performing procedures. In a PP program, you learn many different ways to skin the cat and learn a little from each of them. In academics, there are much fewer ways of doing things because chances are, one of your attendings trained 2-3 of your other attendings (not very diverse).
PP/Community:
Pros:
- You will get very fast and very efficient with your bread and butter radiology diagnoses and procedures (~95% of your work). This is because there are typically no fellows above you and you are often the only trainee on the rotation at any given time. That means that you run the show starting day 1. It is daunting and there is a lot of trial-by-fire, but you will come out the other end fearless, well trained, efficient, and practical. It can be devastating to your ego if you’re not used to getting things wrong, are shy/indecisive or don’t take criticism well. But if you persevere, you will often come out better prepared for the real world than most academic residents.
- No fellows. I cannot overstate this enough. If there are no fellows above you, then you will learn and screw up at an exponentially higher rate than someone who is in a larger program. You CANNOT be a fly on a wall in a PP/Community program as they are typically smaller and usually 100% Resident-run. In an academic program, if you want, you can hide, dodge work and be lazy because the program is not counting on you and there are multiple layers of protection above you. In a PP/Community program, if you miss something, there are real and immediate consequences. If you are not performing well, not producing volume, or are lazy, you cannot hide and there will be conversations with your Program Director to follow. If you don’t work hard, there will be conversations with your Program Director. In short, you are the first line and often have minimal back up, so get ready to work hard and take responsibility much sooner than you want. The layers of protection (people above you) are a double edged sword because they can help shelter you from being dangerous but can also protect you too much so that you don’t grow as a resident until you graduate, real life hits, and there’s no attending or fellow to back you up – get ready for a rough 1st yr of attendinghood.
Cons:
- You may have a harder time getting into a prestigious fellowship. Name recognition matters and even though a small program in Wyoming or Maine may produce better residents than a University of, the bias is there and your application may go by the wayside regardless of talent.
- There are less research opportunities. I know, you hate research (most people do), but you still need it to pad that CV for fellowship and beyond. In academics, attendings are constantly badgering you to do research with them. Not the case in PP/Community. You often have to initiate.
- You may not see as many Zebras as you would in an academic program. And while 99% of the time you’ll be right in diagnosing the common thing as common, you will get burned when that Zebra pops up and you misdiagnose it. For example, appendicitis is common. But sometimes the appendix is enlarged because of a mucocele, not because it is obstructed/inflamed. If the surgeon goes in and spills just a few of those mucinous cells into the peritoneum, the patient will forever be doomed with pseudomyxoma peritonei. It is devastating for the patient and could have been prevented with a better radiology read. The routine things can be worked up at your PP/Community hospital, but a rare bird is better served at a large tertiary care center such as University of. You may have to read books on these instead of getting first-hand experience.
