Are Community Programs Really that Competent?

[automaton]

i hear things all the time about how community programs train just as well as university programs and that the only difference is the emphasis on research. having worked with residents in community programs, i really doubt that is the case. i've seen a lot more errors in community programs, and whenever i ask a question no one seems to know the answer. the community program i'm rotating through now practices cookbook medicine and doesn't know about studies or data, they just do what they're used to, and when i ask why they do this, or the mechanism behind something, they don't know. my classmates at other sites report similar things. honestly, are community programs really training competent physicians? honestly some of the residents function as third year students, with no independent thought process. they just report numbers or the impressions verbatim from consults. some don't know how to read chest xrays or ekgs. i don't know, maybe there are just a few programs that are like this, but it seems weird. what are the experiences of others about community programs?

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[Mumpu]

I'm sure there are very competent community programs. My local program has excellent teaching actually, but you are absolutely correct -- the residents have no autonomy and when **** hits the fan in the middle of the night and the private attendings won't return their pages, there is a lot of "deer in the headlights" and bad patient outcomes. They also turf absolutely all procedures to surgery without even trying.

 

[8744]

On the other hand, as an intern in The Specialty That Dare Not Speak Its Name at a large academic University Which for Shame We Will Not Mention you have got to know that the training suffers because their are so many specialists on whom your complicated patients can and must be referred. Our specialists have specialists.

Not knowing something and not having backup is a tremendous incentive for self-improvement.

You definitely need to do primary care at a small, unopposed community program.

 

[Poety]

On the other hand, as an intern in The Specialty That Dare Not Speak Its Name at a large academic University Which for Shame We Will Not Mention you have got to know that the training suffers because their are so many specialists on whom your complicated patients can and must be referred. Our specialists have specialists.

Not knowing something and not having backup is a tremendous incentive for self-improvement.

You definitely need to do primary care at a small, unopposed community program.

Thats an excellent point Panda 👍

 

[cchoukal]

I've definitely seen some of both. One of the community hospitals back home where I did medical school actually sponsored some really solid residencies in medicine and surgery. I remember being pretty impressed. Right now, though, I'm an intern in a non-medicine specialty at major academic hospital and do a few medicine-intern rotations at an "affiliated" community hospital, and the difference is night and day. Or if there was something that was more extreme than "night and day,
it'd be that. It's really startling, the difference in quality of education. At the community hospital, there aren't really dedicated attendings, but rather private attendings, so there is virtually no teaching on rounds. When there is teaching, it tends not to be based on anything particularly official (like actual data), but rather on traditions of each attendings' practice. When the residents teach, even at conferences, they pretty much just pull slides off of up-to-date. There's a real difference in the work ethic, as well. The residents seem to be focused entirely on just covering the basics so they can run out of the hospital for the day at 1pm.

So this is just a couple examples. I'm sure there are other community programs that are more rigorous and provide better training. As an applicant, though, I'd look REALLY hard to make sure you're getting what you want. As a patient, I never thought I'd put a whole lot of stock in where someone trained, but I feel very different now.

 

[deleted87716]

Whenever you find yourself generalizing about anything, you're probably wrong. 😉

There are good and bad community programs, and there are good and bad academic programs. It's not really a question of "competency," as all residencies must meet the same RRC requirements. Your personal experiences and mine are observational studies with N=1. We're not all looking for the same sort of residency experience, either. Each training program should be evaluated on its own merits, or lack thereof, based on what's important to you personally. You'll get out of residency exactly what you put into it, regardless of where you train.

My personal opinion (N=1) is that it's usually better to learn family medicine in a community program, echoing what Panda said. If your goal is to become a sub-subspecialist of some sort, you're better off sticking with the big academic medical centers, because you'll need to network, and where you train (the "name") will matter more. For everyone else, it really makes little difference.

 

[Mumpu]

For family medicine, for sure. Fam med residents are the scut monkeys of everyone and their mom at academic programs.

There is a difference between the challenge and the need for self-improvement and a senior resident who freaks out in the ICU because they never had to make a decision in their three years of training.

 

[lowbudget]

KentW is right in that you can't judge all programs by the same standards, because people pick different residencies for different reasons.

Addressing some of the issues in the OP:
1. Errors: Errors happen everywhere at all levels of training. Certainly in university programs there are more layers of patient care (med student, intern, resident, fellow, faculty) so it may seem that things are eventually flushed out, whereas in some community program, you don't have division of labor among residents and so residents are in charge of a lot of issues, many of which may be the first time they're encountering them. That said, there were many errors presented in M&M in med school, so I can't imagine there university programs being more perfect than community programs.

2. Med Student Questions: As a med student, you probably spend a huge proportion of your time trying to understand the clinical situation which is great. But as a resident, your brain is focused on so many different things like do I have the right diagnosis, what is the next step, what does this patient need tomorrow, what will it take to get you discharged, what paperwork needs to happen, how do I manage my med students... And so when a student wants to know what interleukin or what G-protein is responsible for a problem, I tell them I don't know (because I'm nice). The malignant residents will ask why the med students don't know anything, ask stupid questions, and to look it up and put together a powerpoint presentation to be presented during rounds the next day. My point is that your priorities as a med student and a resident are different. So don't judge a program on that basis alone.

3. Quoting data: This is an interesting one because EBM is the mantra of our generation of doctors. There needs to be a balance between a resident/faculty's knowledge about an area and the propensity for people to just show off. Again, priorities. Some faculty members don't take care of patients anymore, so they spend their day putting together Grand Rounds material and quoting statistics. That said, people need to have a feel for some of the numbers when they're taking care of patients.

4. General ******ation and cookbook medicine: Hey man, listen. We're residents. We're learning. It's ok to blurt a bunch of BS when you're a med student because med students are dumb and you're expected to be dumb. It's NOT ok to blurt a bunch of BS when you're a resident because residents are dumb, but people expect you to be smart. So when you're a resident, the crap that comes out of your mouth MATTERS. So don't be surprised when the resident doesn't jump up during Grand Rounds to read a chest x-ray and EKG for everyone to laugh at them. Also, don't be surprised when we use the cookbook, especially when the cookbook reflect the STANDARD OF CARE in the community. Stroke, MI, ACLS... these are just a few things where we have protocols that (arguably) are evidence based that are used to ensure patient safety. AND realize that faculty devise cookbooks and algorthims to TEACH medicine while protecting the patient from resident-in-training. When people's lives are at stake, you don't want the resident to be making crap up and start anticoagulating everyone with SOB. Also realize that residents may quote consults verbatim because THAT'S WHY THEY GOT THE CONSULT in the first place. Why consult when you can evaluate and manage the patient yourself (other than CYA)?

5. Residents as 3rd year students: That is correct that on some occasions in community programs you function as a shadowing student. That is because many faculty member volunteer their private patient panels to residents but at the end of the day, the faculty member is making the decisions. These patients went to see a faculty member, not a resident, so it's not all that surprising. At some programs (university/community) there are a lot of patients where some care is better than no care. County & VA are examples of this, maybe indigent/homeless shelters. These patients are perfect patients for resident training because residents are cheap labor for low-paying patients. Some training programs are suffering because the ER is sending away a lot of indigent/non-emergent cases meaning less patients are being admitted. That'll affect your procedures volume and case volume. That is a medical economics reality. Those turned away end up at other institutions where there isn't as much support (nursing, specialists, technology), so if you choose to train at these institutions, realize that it can be equally frustrating when you're not practicing/learning medicine as it should be. It also depends on how hands on your faculty member is and your experience. A 3rd year will have more autonomy than a 1st year, etc.

6. Teaching: There is a difference in teaching at community vs university programs in that there may be a tendency for university programs to be more dedicated towards teaching. But it's only a generalization and very faculty dependent. I've had plenty of non-teaching med school faculty and plenty of hard-core teachers at community programs. So it's a toss up. Best way to evaluate this is to ask residents to name names, i.e. how much teaching does Dr. So-and-So do during rounds, during call, etc.

Anyways, there definitely are differences between community and university programs, some of them subtle, some of them important, others not. I hear your comments, but at the same time, just wait until July 1st when you go from a 4th year know-it-all to a 1st year ****** overnight. Be afraid. Be very afraid.

i hear things all the time about how community programs train just as well as university programs and that the only difference is the emphasis on research. having worked with residents in community programs, i really doubt that is the case. i've seen a lot more errors in community programs, and whenever i ask a question no one seems to know the answer. the community program i'm rotating through now practices cookbook medicine and doesn't know about studies or data, they just do what they're used to, and when i ask why they do this, or the mechanism behind something, they don't know. my classmates at other sites report similar things. honestly, are community programs really training competent physicians? honestly some of the residents function as third year students, with no independent thought process. they just report numbers or the impressions verbatim from consults. some don't know how to read chest xrays or ekgs. i don't know, maybe there are just a few programs that are like this, but it seems weird. what are the experiences of others about community programs?

 

[OUsooner]

I was already ****ting myself before you told me to "be very afraid". thx

 

[automaton]

i understand what lowbudget is saying, and that's all stuff i thought at first too. but my experience at this community program was shocking to say the least.

i don't expect residents to know detailed biochemistry or anything related to second year minutiae. i don't know those either, so i don't really care. but i expect residents to understand why consults are being made, what the general plan is, and what kinds of options there are. when i ask questions, i ask clinical questions. i ask why we are getting imaging tests, why we're getting certain labs, how to clinically differentiate certain physical exam findings over another. i believe these are all fair game. i'm at the end of my third year here, that means the interns are at the end of their intern year. by now they should know a few things about WHY things are happenining, not just WHAT is happening. one example, i was in clinic seeing a patient, and my attending pointed out certain physical exam findings. i ask my resident, who was present at the time, how to distinguish one lesion over another. this resident had no idea, yet she said "ok ok" when the attending was there. i had to ask the attending directly.

as far as EBM and cookbook medicine, i don't need someone to quote numbers or obscure journals about how many people have nausea with anti-hypertensives or anything stupid like that. i'm talking about things that actually matter. like when i was on medicine we learned that diuretics are first line, beta blockers have cardiac benefits, and ace-inhibitors are first line for diabetes to protect from diabetic nephropathy. that's BASIC, RELEVANT, evidence based information. it all goes back to clinical questions. when i ask why things are done instead of other ways, i want them to know. when residents just say "i don't know", or "that's what the attending said, i don't know why", that is embarrassing. how will they make decisions in the future without understanding the reasoning for certain decisions?

another example of EBM, is knowing the utility of ultrasound vs xray vs ct vs mri. i'm not talking about spitting out facts like, ultrasound has a sensitivity of 94.59834%. i'm talking about, "in this situation, an MRI is better than CT for so-and-so reason, cuz you can find x,y,z on MRI that you can't find on CT.

regarding errors, obviously a few experiences can alter perceptions a lot, so i have to not interpolate too much, but it's part of the overall vibe that i get from the residents. they don't have as much of the attention to detail that i'm used to at the university setting. people at the university read and know the basis for differentials. they involve themselves in the management plan, and even as third years we are responsible for presenting the plan to attendings, and having a grasp of what is going on. they know the important data that says when a patient should be treated medically or surgically, what the utility of certain tests are over others. when they order tests they look at it and try to learn from every experience. at the community i found that most were satisfied to just get through the day the easiest way possible, simply reporting facts and letting higher-ups do all the decision making. i mean if you're going to do that, why not be a nurse? (no offense, but that's their job). they never ask me for my input. at the U i had to at least attempt to interpret my own consults, imaging, or ekgs. the points i make about lack of detail and thinking, lead to carelessness and mistakes. everyone is learning, sure, and mistakes will happen anywhere, even to the best. but i see more attention to detail and effort to make the correct decisions. whether the numbers bear that out i don't know.

lastly, anywhere you go you will have people that maximize their experience and those that squander them. there are people at my med school who just report crap. i've done that too. i am not the most motivated student out there, so i'm not trying to sound indignant or high and mighty. but the bar at the community program i rotated in, was much much lower. so low that i question whether anyone can confidently say that all US residencies produce competent physicians. anyone can practice multiple choice questions and pass national boards with knee jerk responses to classic case presentations. but life is not so clear cut, and you need to understand nuances to be a good physician. how can you do that if you are not expected to?

 

[GuP]

offtopic, but how does one know whether a program is community or academic? is there a site that categorizes them?

 

[DRDARIA]

offtopic, but how does one know whether a program is community or academic? is there a site that categorizes them?

If you go to the FRIEDA website (just google FRIEDA) and look up a program, there is a space where the program categorizes themselves into "University based, Community based, University affiliated, Academic-other", etcetera. So that will give you an idea what the program considers themselves to be. (I'm not sure I got the categories exactly right, but you get my point).

A little more obviously is programs that are not part of a university but are affiliated with a non-university hospital are GENERALLY community, and the ones that are part of a university hospital are considered university based. There are combinations of course, and some university hospitals use community hospitals part of the time, as well as VAs. So there are all sorts of combinations.

Hope that helps.

 

[Smurfette]

i understand what lowbudget is saying, and that's all stuff i thought at first too. but my experience at this community program was shocking to say the least.

i don't expect residents to know detailed biochemistry or anything related to second year minutiae. i don't know those either, so i don't really care. but i expect residents to understand why consults are being made, what the general plan is, and what kinds of options there are. when i ask questions, i ask clinical questions. i ask why we are getting imaging tests, why we're getting certain labs, how to clinically differentiate certain physical exam findings over another. i believe these are all fair game. i'm at the end of my third year here, that means the interns are at the end of their intern year. by now they should know a few things about WHY things are happenining, not just WHAT is happening. one example, i was in clinic seeing a patient, and my attending pointed out certain physical exam findings. i ask my resident, who was present at the time, how to distinguish one lesion over another. this resident had no idea, yet she said "ok ok" when the attending was there. i had to ask the attending directly.

as far as EBM and cookbook medicine, i don't need someone to quote numbers or obscure journals about how many people have nausea with anti-hypertensives or anything stupid like that. i'm talking about things that actually matter. like when i was on medicine we learned that diuretics are first line, beta blockers have cardiac benefits, and ace-inhibitors are first line for diabetes to protect from diabetic nephropathy. that's BASIC, RELEVANT, evidence based information. it all goes back to clinical questions. when i ask why things are done instead of other ways, i want them to know. when residents just say "i don't know", or "that's what the attending said, i don't know why", that is embarrassing. how will they make decisions in the future without understanding the reasoning for certain decisions?

another example of EBM, is knowing the utility of ultrasound vs xray vs ct vs mri. i'm not talking about spitting out facts like, ultrasound has a sensitivity of 94.59834%. i'm talking about, "in this situation, an MRI is better than CT for so-and-so reason, cuz you can find x,y,z on MRI that you can't find on CT.

regarding errors, obviously a few experiences can alter perceptions a lot, so i have to not interpolate too much, but it's part of the overall vibe that i get from the residents. they don't have as much of the attention to detail that i'm used to at the university setting. people at the university read and know the basis for differentials. they involve themselves in the management plan, and even as third years we are responsible for presenting the plan to attendings, and having a grasp of what is going on. they know the important data that says when a patient should be treated medically or surgically, what the utility of certain tests are over others. when they order tests they look at it and try to learn from every experience. at the community i found that most were satisfied to just get through the day the easiest way possible, simply reporting facts and letting higher-ups do all the decision making. i mean if you're going to do that, why not be a nurse? (no offense, but that's their job). they never ask me for my input. at the U i had to at least attempt to interpret my own consults, imaging, or ekgs. the points i make about lack of detail and thinking, lead to carelessness and mistakes. everyone is learning, sure, and mistakes will happen anywhere, even to the best. but i see more attention to detail and effort to make the correct decisions. whether the numbers bear that out i don't know.

lastly, anywhere you go you will have people that maximize their experience and those that squander them. there are people at my med school who just report crap. i've done that too. i am not the most motivated student out there, so i'm not trying to sound indignant or high and mighty. but the bar at the community program i rotated in, was much much lower. so low that i question whether anyone can confidently say that all US residencies produce competent physicians. anyone can practice multiple choice questions and pass national boards with knee jerk responses to classic case presentations. but life is not so clear cut, and you need to understand nuances to be a good physician. how can you do that if you are not expected to?

You have some rather high expectations. As a resident, I myself do not always have the ability to get an answer as to WHY something is the way it is or why a patient is getting a test. This is not because I am stupid, but because no one has explained it to me as well and for any number of reasons, I cannot or did not get an answer from whomever wanted that particular med/test/whatever.

There are a lot of things that go on that students are not privy to....so if I don't know because my senior resident never explains anything to me or because the attending doesn't want to waste his precious time explaining something to an intern, I am not going to tell the student "Dr. X hates residents and thinks everything he says should be followed without question"....because I feel that it is inappropriate and unprofessional to discuss that with a medical student. So if a med student asks me something I don't know, I reply "I don't know" and sometimes "why don't you ask so-and-so, because I don't know either". And sometimes things are being done that are NOT the standard of care, and you aren't sure why we aren't doing what we have the other 99% of the time, and your chief resident is pissed off about it too because the attending deviated from the standard of care for a reason that the chief disagrees with or doesn't understand either....so the students never get an explanation either, because residents don't usually want to explain that they disagree with the patient management. Not that this accounts for all the situations you are talking about, but that could be some of it.

Once you become a resident, you will find you'll hear more "I can't believe we're doing this instead of that" comments, and you will find out which attendings are or aren't respected as well....people try to cushion med students from this.

 

[automaton]

thanks for your insight. i can see how those cases would come up, and they have before in all situations. a few puzzling cases here and there aren't what i'm really alluding to. i guess if i mentioned the specific examples it would be clearer where my surprise comes from, but i'd rather not do that. sorry if i offended interns or residents by making the job seem easy. i know it's not, and med students don't demand perfection. there are just some things that really make you scratch your head though, like my experiences at a specific community hospital. let's just say it was very bad.