Another fellow vs no fellow...

[dollarbill]

Would just like some more feedback from current residents/applicants on thoughts. I realized that most of my 4th yr rotations were done at medium size programs with little fellows. I am stuck with some of these larger programs that I liked but due to lack of experience regarding fellows impact on education still having a hard time gauging. On the interview trail, programs would twist this to their advantage...smaller programs saying how you have so much 1-1 with attending and first dibs on procedures. Than you have the larger ones saying they have the #s for fellows and once fellows procedure quota is met in the first months everything is open. My top 2 choices basically boil down to fellows vs. little fellows. I am interested in pursing a fellowship after residency. Thanks in advance.

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[SurfingDoctor]

Would just like some more feedback from current residents/applicants on thoughts. I realized that most of my 4th yr rotations were done at medium size programs with little fellows. I am stuck with some of these larger programs that I liked but due to lack of experience regarding fellows impact on education still having a hard time gauging. On the interview trail, programs would twist this to their advantage...smaller programs saying how you have so much 1-1 with attending and first dibs on procedures. Than you have the larger ones saying they have the #s for fellows and once fellows procedure quota is met in the first months everything is open. My top 2 choices basically boil down to fellows vs. little fellows. I am interested in pursing a fellowship after residency. Thanks in advance.

I'm not sure who told you this and in what context, but this is very inaccurate. While there are a somewhat arbitrary, program-specific, number of procedures fellows must complete to graduate fellowship and fulfill ACGME procedural competency, it is certainly not achieved in the first few months. In my personal opinion, no first or second year fellow should ever give up a procedure. Maybe, if they done enough, without error, as a third year, they can instruct a resident on how to perform a procedure (which is a useful skill), but even then, I think fellows should do as many procedures as they can get their hands on because when they graduate 2 things happen; 1) there is no more backup and no one senior to get it for them, they are the attending and 2) depending on where they go, they may not get to actually do procedure much at all (I get maybe 1 intubation a year... maybe). So they need to get as much hands on experience as possible to overcome those issues. Having a resident do a procedure in lieu of fellow is a disservice to a fellow who needs that skill for the rest of their career, while a resident most likely does not and is just doing to say they did it. Of course, there is the issue of patient safety in having less experienced people do procedures that has been well-documented, but that is besides the point.

In either case you are mentioning, small vs. large, since you will have only brief exposures to the rotation related to your fellowship interests (I assume you are talking about NICU, PICU or ER, but maybe something else), there will be no real advantage from a procedure standpoint because you will not learn competency in those procedures during your resident training. That is why they have fellowship training. And there is no expectation that a incoming fellow has competency in a procedure and doing more procedures as a resident doesn't help you chances for matching into a fellowship program of your desire. The issue more important is somewhat you said as far as 1-1 faculty interaction and exposure. This is important for 2 reasons; 1) you need that facetime and interaction so that you can get good LORs for your future fellowship application and 2) you may be able to be involved in a project (no matter how small) with a faculty that you can write on your application. In a smaller program, you would likely have to interact more with the faculty, given the absent of fellows as go between, but you also may be limited in the projects you can get involved because the number of faculty are more limited.

I'm not sure where you are looking and what fellowship you are planning to pursue, but I would advice against choosing a residency program based on whether or not you think you'll be able to get more procedures in one versus the other, especially in the context of pursing fellowship afterwards

 

[Mountaineer12]

I'm in the same boat, OP. I can't decide if I buy into everyone telling me fellows are so great to have around.

How about fellows vs. no fellows in creating assessment/plan for your patients? I've heard that at programs with a lot of fellows the resident is often told what the A/P is instead of coming up with it on their own vs. a smaller program with limited fellows and more autonomy to make decisions. How true is this?


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[oldbearprofessor]

In my view, and I've been on both sides of this fence in leadership roles, it makes very little difference. Pick the program that is the best match for you in terms of the people, the city, the program structure, etc, etc. Any middle-sized program will have lots of its residents getting excellent fellowship matches. The procedure issue is a draw for all the reasons already mentioned and more. Don't go to a program you don't think is the best fit for you over this issue, IMHO.

 

[SurfingDoctor]

I'm in the same boat, OP. I can't decide if I buy into everyone telling me fellows are so great to have around.

How about fellows vs. no fellows in creating assessment/plan for your patients? I've heard that at programs with a lot of fellows the resident is often told what the A/P is instead of coming up with it on their own vs. a smaller program with limited fellows and more autonomy to make decisions. How true is this?


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I think it would a disservice to residents if they weren't allow to come up with an assessment and plan. That's kinda the whole point of residency. I have personally not seen a resident not have the option with coming up with an assessment and plan.

Autonomy is different though and I think resident autonomy is independent of if there are fellows or not. If a resident wants to make a change in the plan or treatment, I think that is fine, but after its been discussed. I don't think a fellow alters that in anyway.

 

[mvenus929]

I'm in the same boat, OP. I can't decide if I buy into everyone telling me fellows are so great to have around.

How about fellows vs. no fellows in creating assessment/plan for your patients? I've heard that at programs with a lot of fellows the resident is often told what the A/P is instead of coming up with it on their own vs. a smaller program with limited fellows and more autonomy to make decisions. How true is this?pp

I came from a program with few fellows. It is theoretically possible for a resident to skate through residency without definitively coming up with a plan in their own. Some attendings are better than others at pushing residents to deliver their plan. That is probably going to be the same in either program.

I do appreciate being in a program with fewer fellows, as I am able to get to know my attendings well and get great mentorship in the process. There is some hesitancy to call our attendings at night, but all of them encourage it and our program allows the seniors to truly be the first line for decisions and admissions to the general service, so we all feel petty capable when we graduate.

 

[Mountaineer12]

Thanks everyone! 🙂


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[thetubes]

As everyone else has said before I don't think this should be a major deciding factor. However, I do think it is important and probably for different reasons than the other posters. I get the vibe that most residents would prefer to not have fellows but I have to disagree. The fact that there are fellows suggests that the division is strong, has an adequate patient volume, opportunities for research/funding, all of which would enrich your experience while rotating with that service and make you an attractive candidate when you apply for fellowship. People also talk about how fellows would limit the opportunity to perform procedures; this may be true for PICU/NICU/EM where you mostly do intubation/place lines but if you are specializing in most other fields, the procedures are highly specialized and really require dedicated training in the sim lab to safely perform them on patients as a learner vs just mucking around (ie GI endoscopy, bronchoscopy, cardiac caths). My 2 cents.

 

[dbeast]

If you're going to do gen peds and want to get procedures while you have the chance, go to a no-fellow program. However, if you want to do a fellowship, you should definitely go to a program with fellows. You'll have to wait on the procedures as a resident (sorry) but it will help you make connections for that fellowship... at which point you'll become the big dawg stealing all the procedures. That should settle your decision.

 

[Mountaineer12]

If you're going to do gen peds and want to get procedures while you have the chance, go to a no-fellow program. However, if you want to do a fellowship, you should definitely go to a program with fellows. You'll have to wait on the procedures as a resident (sorry) but it will help you make connections for that fellowship... at which point you'll become the big dawg stealing all the procedures. That should settle your decision.

What if you're undecided? Haha I'm leaning towards gen peds, but wouldn't be totally surprised if that changes.

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[mvenus929]

What if you're undecided? Haha I'm leaning towards gen peds, but wouldn't be totally surprised if that changes.

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My program just matched three people into NICU, one into Endo, one into GI, one into EM, and one into Hospitalist. We have two applying for Heme/Onc and one for cards right now, and I have no doubt that all three will match. Of those, the only fellows we have are EM. In recent years, we have also sent people to Allergy, Pulm, ID, Adolescent, and PICU. The only person in recent years I've heard of not matching was someone who was struggling in residency at baseline and made some not so wise decisions in the match process.

Yes, having a fellow means that you have enough variety and volume to support one, but not having a fellow doesn't mean that you don't have the variety or volume. My Med school had an Endo fellow while I was there, and my residency has at least 3 times the volume of that program, but we don't have an Endo fellowship. They also had two NICU fellows per year, and we are just slightly smaller for our level III/IV, but much larger for our level II. They had one PICU fellow per year as well, and our PICU is most definitely larger than theirs, though the acuity maybe slightly different (we don't do many transplants here, and they do, and we don't have a step down unit here, but we definitely have more traumas). And we have plenty of research opportunities in all those.

Ask around at your interviews to see whether people go into fellowship, and how successful they are at matching. If you're already passed the interviews and didn't ask, ask the coordinator for someone in the program you can ask some followup questions to, if you were not already given emails. Or even for the match list from recent years. Most places happily advertise it.

In the end, it's better to go with your gut feeling for which program you'd fit in better at, than deciding based on whether or not there are fellows present.

 

[thetubes]

Yes, having a fellow means that you have enough variety and volume to support one, but not having a fellow doesn't mean that you don't have the variety or volume. My Med school had an Endo fellow while I was there, and my residency has at least 3 times the volume of that program, but we don't have an Endo fellowship. They also had two NICU fellows per year, and we are just slightly smaller for our level III/IV, but much larger for our level II. They had one PICU fellow per year as well, and our PICU is most definitely larger than theirs, though the acuity maybe slightly different (we don't do many transplants here, and they do, and we don't have a step down unit here, but we definitely have more traumas). And we have plenty of research opportunities in all those.

Well that may be true but a pediatric department with a fellowship in that division is pretty much guaranteed to have adequate volume for that field or else that fellowship program would be in jeopardy. On another note, I think the one thing that people tend to overlook is that half of your fellowship is research and fellowship programs want fellows who can demonstrate that they are able to conduct research. Thus, an attractive candidate for fellowship would have conducted research in that field and the chances of having this done in residency are much higher if someone goes to a program with an active fellowship in that field. If you want to end up in academic medicine, having a research track record in that field should start as early as possible, possibly in residency. This was essential to me landing a competitive training grant and would not have been possible if I went to a program that didn't have an active fellowship and thus ample research opportunities/faculty who are engaged in research.

 

[SurfingDoctor]

I would disagree that just because a program has fellows, research projects are easier to do or get. It is simply a matter of effort on the part of a trainee. I went to a residency program with no fellows, but still did a project and probably put it more research effort in residency that than the typical applicant. Opportunities exist if you seek them out no matter where you go. Sometimes you do have to be a little bit more creative, but that looks favorably when I look at applicants because they went the extra mile.

 

[Perrotfish]

Some thoughts from my experience rotating through a fellowship heavy children's hospital:

1) ) Children's hospitals are full of doctors who have never worked outside of a Children's hospital. That's great, I guess, if your ambition is to be an academic Infectious Diseases attending, working 55 hours/week for 75K/year, but if you hold out some hope of getting a real job subspecialist attendings in a fellowship program are singularly bad judges of what is and is not important for you to learn. That's true both because of their lack of exposure to the real world, and the fundamental lack of perception that landed them a job as an academic subspecialist to begin with. Its like you found an Orca that was raised in captivity since birth, and you chose it to be your mentor in the world of merchant banking. My personal favorite was the NICU attending who though that one day, in my community hospital, I might need to put a kid on a Jet ventilator and therefore needed to know how to properly adjust the settings.

2) Multiple Co-equal bosses make every day equally miserable. When I rotated through my home (small hospital) system as an Intern I reported to a senior resident, who reported to an attending. When I rotated through the children's hospital I reported to a senior resident who reported to eight attendings, some directly and some through the intermediary of fellows. When my one attending in my home hospital really wanted something done right away, he knew that he was asking us to put his high priority item ahead of his other, lower priority items, and then understood when those low priority items took a really long time to finish. When I rotated through the children's hospital each attending generally had one or two items that they needed done at a given moment in time, but they made it very clear that their item was TOP PRIORITY and should be bumped ahead of every other attending's items. Obviously you can't have 8 different top priorities, so you spent your day wandering through a withering haze of attending and fellow abuse.

I meant this to be a more balanced comparison of fellowship vs non-fellowship hospitals, but looking back I just really hated that hospital.

 

[call me x]

I don't think it should be your deciding factor, but it is a little bit personal preference. For residency, most of my top choices were large, northeast academic programs with lots of fellows. I am at a busy free-standing children's hospital with lots of fellows and have enjoyed it. I like seeing what life is like for fellows and interacting with them and attendings (for the most part hah). I am specializing and have matched, and feel I got more-than-enough direct interactions with attendings at my program. Have I ever done a bone marrow biopsy? No- but that's what fellowship is for. On every fellowship interview I asked if I, as someone from a fellow-heavy institution, would be at a disadvantage or viewed negatively since I have limited procedure experience. EVERY time the answer was absolutely not. Hope that helps. Anyone saying one way is SO MUCH better than the other is just going off what happened to work for his or her personality, when I honestly think most people could excel in either.

 

[thetubes]

Perrotfish, I hope you're being sarcastic.

 

[Perrotfish]

Perrotfish, I hope you're being sarcastic.

Hyperbolic yes. If I was sarcastic I would mean the opposite of what I'm saying. So no.

 

[PTPoeny]

The most important part of getting into fellowship is doing well in residency and getting good letters. Go where you think you will be happiest as it will be easier for you to excel as a resident when you are happy. I was surprised when I was interviewing that I liked the medium sized programs much better than the large programs. After talking with a number of people, I went with my gut and ranked programs by where I felt most comfortable. Therefore, I ended up at a medium sized program with no fellows and I was very happy there and I am sure I was a better resident for being happy. I am now a fellow and there are differences in the experiences that the residents get and sometimes I feel bad that I am going to do the procedures and I am going to make a lot of patient management decisions whereas I also got to do those things as a resident. At the same time, going to a big program with fellows definitely will not hurt you. The fellowship programs across the country know each other and interact at some of the program director things and so if you go to a big program with fellows the faculty there will definitely know lots of other faculty across the country. If you go to a smaller program with no fellows the faculty may or may not be as involved. There was one fellowship program that I was very interested in so when I hadn't heard from them regarding an interview I called and had a great discussion with the fellowship director. She told me that my application had initially been passed over because I was from across the country and they didn't know anyone from my residency. I expressed a genuine interest in being in that location (in-laws) and we talked about my experiences in residency. That program director told me that her very best fellows had come from programs without fellowships because the residents can step up and really take ownership of their patients. However, they had some bad experiences with residents from small programs as well and are now hesitant to take fellows from residency programs they don't know much about.

 

[thetubes]

Perrotfish, thanks for the reassurance; grammar was never my thing! To the original poster, I think the bottom line is you need to figure out what you want to do in life. If you are dead set on a certain field and hope to one day be a division chief at "Large Quaternary Care Hospital" then I think ending up at a program with fellows is probably what you want to do. If you look at who ends up getting grants like the PSDP, the recipients are almost always from large residency programs with established fellowships. Regarding residency learning at programs with fellows, if you're lucky, the fellow will let you formulate your own assessment/plan instead of just spitting out orders. I do this with the residents/students when I'm on service and I think it works out well; the optimist in me tells me most fellows do this or are at least receptive to the idea when reminded.