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There are malignant programs out there. I won't dispute that.

I don't disagree with anything @AnonymousPD has written here. If you want to disagree with him, be specific. Don't just hurl personal attacks.
Unfortunately, I have to agree that there are a number of ways programs can fail to meet the needs of their residents. Some are beyond the program’s ability to change, but I feel the actions most damaging to resident well-being stem from acting in ways that adversely affect the residents when there are other options. One example of this are the “We are going to rank you to match” letters that are going around now. I would advise anyone who is cancelling an interview at a program of interest because you have a few of these in hand to strongly reconsider doing so.

I would also welcome anyone who does disagree with me to please do so. The students and residents here would only benefit from thoughtful discussion and vigorous debate.
 
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How do you feel about sub specialization affecting your program and non university positions? Specifically, with respect to call, compensation, daily scheduling? At trauma centers it takes a minimum of 3 radiologist to review trauma studies in a patient. A neuro, chest and body imager. All have to be on call each night. If a post open heart patient is bleeding and returns to the OR later that night, does a subspecialist come in for the case or does the generalist on call get a field promituon to handle a cardiac patient? I personally feel sub specialization diminishes quality of life. Your comments might be useful to residents ruminating over whether to do a fellowship. Thank you for posting on this forum. Not many program directors here.
Angus,

First of all, how with respect to how sub-specialties affect non-university practices in the areas you mentioned, I must defer to the others here who are living that experience every day. They are much more qualified to speak about it than I am.

Discussion of sub-specialization and academic medicine, the call burdens, comp and scheduling models needs to start with which sub-specialty you are talking about. You can imagine the call a chronic pain specialist takes bears no resemblance to the call a cardiac specialist takes. I would say that most sub-specialties outside of pain will obligate you to a regular amount of after-hours work. How much will mostly depend on your surgeons (the amount of work there is) and the size of your group (how the work can be spread around).

At my institution, our compensation model is partially tied to call, with the ability to trade calls to other faculty if you are willing to give up the pay that goes with that night. As a general observation, what you will see is older faculty who are at a different stage in life both financially and physically (being up all night gets tougher unfortunately), are more than happy to give up calls to their younger and hungrier colleagues. But even this has its outliers, I can think of one of our cardiac faculty who is well into practice who takes so many extra shifts that some of us wonder if he might not be the highest paid member of the entire department. In the example you listed, at my institution if a cardiac case comes in, the cardiac on call faculty and resident come in to handle it. However there is some overlap with the generalists with respect to certain thoracic and vascular issues.

To the residents who are considering fellowships and want to weigh quality of life issues, I would tell you to look closely at your own experiences during training. How disruptive did you find being on home call vs. being in-house? Which clinical environments did you enjoy the most? What constitutes a “high quality of life” varies from individual to individual. By that I mean we would all love to be compensated fabulously, work when we want, and do only what we want. But from a practical standpoint, the balance between hours/compensation/autonomy/availability are different for everyone.
 
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What do you believe is the appropriate role for CRNAs in the setting of a residency program? Resdients providing breaks for CRNAs? CRNAs providing space for resident lectures? Residents taking all call and staying late? Residents doing advanced cases and procedures or sharing everything? Teaching residents how to manage and medically direct CRNAs? Creating a future resident that's in fact a doc disguised as a CRNA?

When an applicant asks what is a typical PDs view on resident protection?
Modanq,

Okay lots to unpack one question at a time. Forgive me for not being able to quickly figure out how to format the reply so that each question is associated with each response.

As a matter of general principle, I feel that CRNAs at an academic institution exist to support the clinical footprint so that resident training is sufficiently broad and the trainees are able to make properly informed choices with respect their post-residency plans. In other words, if you are grinding out all of the cases, when are you going to have time to do research, participate in QI, go to meetings, study for boards, go to the sim lab, interview for jobs/fellowships, or any of the dozens of other things you do during residency?

No…the CRNAs should be giving breaks. Or preferably faculty should be doing this, as the more time faculty spend with residents the better. I don’t have a problem with residents breaking other residents if its occurring in the context of teamwork and solidarity. So outside of individual situations where you need to break someone out because its the right thing to do, I would work to change a situation where faculty board runners were using residents to break CRNAs as a matter of routine policy.

No, CRNAs should not be providing space for resident lectures. This is the responsibility of the “Sponsoring Institution.” I would refer you to the ACGME common program requirements, section I.D.1.a:
“There must be adequate space and equipment for the educational program, including meeting rooms, classrooms with visual and other educational aids, study areas for residents, office space for faculty members and residents, diagnostic and therapeutic facilities, laboratory facilities, computer support, and appropriate on-call facilities for male and female residents and faculty members.”
I have first-hand knowledge of programs that have successfully used this requirement in negotiations with their hospital administrators in order to secure or update resident facilities. It makes sense…there are a number of benefits to a hospital from having residents there. Beyond just financial for the cynics out there. If hospital administrators can be made to understand that these benefits will go away if they don’t support the educational mission, they can also be made to understand that it will be wise to make the proper investments. A new projector, re-purposing a rarely used conference room, a little furniture…those are rounding errors in a hospital budget.

Taking all the call and staying late? I might ruffle some feathers here, but I feel taking call and staying late to finish cases helps prepare you for life in practice as well as helping you understand what sort of job you should be looking for. Certainly there is a limit to this and I would never say that residents staying till 7pm each and every night or taking all the call is a good thing. You guys need time to study and do all the other things residents have to do in addition to living your lives. I would ask some of the private practice partners here to chime in on this one…how would you feel about a junior associate or potential candidate if they are always wondering about when they are going to get relief and aren't particularly interested in taking a personal interest in making sure the work your group has contracted to provide is done completely and at a high level?

As far as I’m concerned residents should always get priority for advanced cases and procedures. Nothing gets our team here on the phone to site directors and board runners faster than when we hear about a resident who got stuck draining abscesses while a CRNA was doing an open vascular case. The presence of a SRNA program can make this more difficult to accomplish in practice, but their educational experience is not my responsibility.

Managing CRNAs. Yes…this is something I feel all residents need exposure to during training. If you hate it during training…presto, you now know you might be happier finding a job doing solo cases in an MD only practice. Furthermore, I think limiting resident exposure to difficult CRNAs does the trainees a disservice. It has not been my experience that dealing with difficult people stops after graduation. Development of social and emotional intelligence is an aspect of residency that is rarely talked about. We need to make sure you are always supported, treated professionally with respect, and have faculty available to mediate issues. But we don’t think it’s appropriate to alter your schedule because someone might not like you or you might not like them.

Creating residents who act like CRNAs. Sadly, I think this one is mainly up to the residents. Are you going to going to cause a stink about relief every time you’re still in a case at 3pm? Are you going to study and learn why we do things or settle for just knowing the how? Are you going to find a way to add value to an organization other than just engaging in scheduled clinical activity? As programs we can only do so much. Some of us have more resources and better facilities than others, that’s for sure. And programs can do things like shifting resident supervision to the group of faculty that are the best role models. But ultimately it is up to the trainee himself to decide what kind of doctor he wants to be.

I would ask you to elaborate on what you mean by protection. That can refer to a lot of different things, and different problems require different solutions.
 
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Modanq

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Modanq,

Okay lots to unpack one question at a time. Forgive me for not being able to quickly figure out how to format the reply so that each question is associated with each response.

As a matter of general principle, I feel that CRNAs at an academic institution exist to support the clinical footprint so that resident training is sufficiently broad and the trainees are able to make properly informed choices with respect their post-residency plans. In other words, if you are grinding out all of the cases, when are you going to have time to do research, participate in QI, go to meetings, study for boards, go to the sim lab, interview for jobs/fellowships, or any of the dozens of other things you do during residency?

No…the CRNAs should be giving breaks. Or preferably faculty should be doing this, as the more time faculty spend with residents the better. I don’t have a problem with residents breaking other residents if its occurring in the context of teamwork and solidarity. So outside of individual situations where you need to break someone out because its the right thing to do, I would work to change a situation where faculty board runners were using residents to break CRNAs as a matter of routine policy.

No, CRNAs should not be providing space for resident lectures. This is the responsibility of the “Sponsoring Institution.” I would refer you to the ACGME common program requirements, section I.D.1.a:
“There must be adequate space and equipment for the educational program, including meeting rooms, classrooms with visual and other educational aids, study areas for residents, office space for faculty members and residents, diagnostic and therapeutic facilities, laboratory facilities, computer support, and appropriate on-call facilities for male and female residents and faculty members.”
I have first-hand knowledge of programs that have successful used this requirement in negotiations with their hospital administrators in order to secure or update resident facilities. It makes sense…there are a number of benefits to a hospital from having residents there. Beyond just financial for the cynics out there. If hospital administrators can be made to understand that these benefits will go away if they don’t support the educational mission, they can also be made to understand that it will be wise to make the proper investments. A new projector, re-purposing a rarely used conference room, a little furniture…those are rounding errors in a hospital budget.

Taking all the call and staying late? I’m might ruffle some feathers out there, but I feel taking call and staying late to finish cases helps prepare you for life in practice as well as helping you understand what sort of job you should be looking for. Certainly there is a limit to this and I would never say that residents staying till 7pm each and every night is a good thing. You guys need time to study and do all the other things residents have to do in addition to living your lives. But I would ask some of the private practice partners here to chime in on this one…how would you feel about a junior associate or potential candidate if they are always wondering about when they are going to get relief and aren't particularly interested in investing themselves into the work your group has contracted to provide.

As far as I’m concerned residents should always get priority for advanced cases and procedures. Nothing gets our team here on the phone to site directors and board runners faster than when we hear about a resident who got stuck draining abscesses while a CRNA was doing an open vascular case. The presence of a SRNA program can make this more difficult to accomplish in practice, but their educational experience is not my responsibility.

Managing CRNAs. Yes…this is something I feel all residents need exposure to during training. If you hate it during training…presto, you now know you might be happier finding a job doing solo cases in an MD only practice. Furthermore, I think limiting resident exposure to difficult CRNAs does the trainees a disservice. It has not been my experience that dealing with difficult people stops after graduation. Development of social and emotional intelligence is an aspect of residency that is rarely talked about. We need to make sure you are always supported, treated with respect and professionalism, and have faculty available to mediate any issues. But we don’t think it’s appropriate to alter your schedule because someone might not like you or you might not like them.

Creating residents who act like CRNAs. Sadly, I think this one is mainly up to the residents. Are you going to going to cause a stink about relief every time you’re still in a case at 3pm? Are you going to study and learn why we do things or settle for just knowing the how? Are you going to find a way to add value to an organization other than just engaging in scheduled clinical activity? As programs we can only do so much. Some of us have more resources and better facilities than others, that’s for sure. And programs can do things like shifting resident supervision to the group of faculty that are the best role models. But ultimately it is up to the trainee himself to decide what kind of doctor he wants to be.

I would ask you to elaborate on what you mean by protection. That can refer to a lot of different things, and different problems require different solutions.
Excellent response.
 

Leinie

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One example of this are the “We are going to rank you to match” letters that are going around now. I would advise anyone who is cancelling an interview at a program of interest because you have a few of these in hand to strongly reconsider doing so.
I received one of these letters nearly two decades ago. I did not match at the program that sent it to me. I would heed this advice.

Leinie
 

Clockdoc89

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Thank you for doing this!

How bad is it if I did well on step 1 (high 240s) but didn't honor a rotation? Assuming step 2 is on par or a bit higher would I still be competitive for top programs? Not really involved in extra curriculars or research either.
 
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Thank you for doing this!

How bad is it if I did well on step 1 (high 240s) but didn't honor a rotation? Assuming step 2 is on par or a bit higher would I still be competitive for top programs? Not really involved in extra curriculars or research either.
Clockdoc,

How is your application affected given that you didn’t honor any classes? It depends on your school and how they have decided to distribute their grades. While some medical schools are still somewhat traditional and award Honors to the top 10% of a class, many are far less exacting. There’s an application on my desk right now where the school gave Honors to somewhere between 60% and 75% of the entire class for every rotation. Being outside the top 10% on all rotations is one thing, being inside the bottom 33% on all rotations is something different. Good MSPE’s (Dean’s letters) can help flesh out your medical school experience and give us some context outside of raw numbers.

As for your USMLE scores, the 2019 update we received told us that the mean and (SD) last year was 230 (19) for Step 1 and 242 (17) for Step 2. Assuming you go 245/245 you would be at the 76th percentile on Step 1 and 54th percentile on Step 2. This is very different from 15 years ago when the mean scores were about 220. Back then, 245s meant you were in the 90th percentile. I doubt there are any programs today that would feel scores in the high 240s are concerning in any way, but at top programs you can expect to be competing with hundreds of applicants with higher scores. So even though you might not have a ton of activities or research, the rest of your application is going to be important.

There was an earlier question about program side logistics of this process. Here’s a peek behind our curtain now that we’re finished with interviews. We received about 1500 applications this year. Because it is not possible to review all 1500, even with PD/APDs and several experienced faculty members helping, we must apply various filters. Steps 1 and 2 are two of these. We set things up in a way that results in us hand reviewing about 500 applications, which includes high potential applicants that we are made aware of that would have otherwise been screened out. This takes time and is the reason interview offers can be delayed. It takes me between 20-30 minutes to thoughtfully review a file the first time. Applicant files are reviewed by at least 2 members of the team and I think we invited a little more than 300 candidates to visit with close to 250 making the trip this season.

I can’t speak for anyone else out there, but for us this is pretty much all the scores are good for. To help sort a mass of applications into a pile of 500 that our finite human resources can give their full attention to. After interviews there are multiple stages of review and the rough rank list is refined into the finished one. During this process, large differences in Step scores might cause an application to move up or down a little, but the effect here is much smaller than what I think most would predict. An application with 255/265 will often only be 5 spots above a similar application with 220/235. I can state unequivocally that I’ve never seen us rank anyone at 120 that would have moved into the top 25 with better scores.

Think about it this way. Your extra curriculars, research, personal statement, hobbies, all of that...those are the tools you have to tell us who you are. If your scores and grades are the totality of your application, then okay that's all we'll use. In a sense, your test scores are only as important as you choose to make them. The back half of our rank list is littered with shiny 250s because those applicants couldn’t demonstrate being good at anything other than taking a test. Last week we interviewed someone who went 250s/250s and we are not going to rank them at all. I won't deny USMLE scores are a necessary part of everyone's application process. But they are less important than taking outstanding care of patients, your grades, being teachable, routinely prioritizing the needs of others, the ability to give maximal effort at all times, and being someone that makes positive contributions to their workplace/coworkers/specialty. It’s likely you’ve made a habit of doing many of those things. But unlike standardized test results, those are things we won't know unless you tell us.
 
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