Are prestigious residencies a scam?

[Choсolate]

I will be matriculating into medical school in the fall. I have another forum about my indecision of what medical school to attend (DO or MD), which has led me to deeply reflect on the consequences of my decision including what residencies I would be able to attend based on what school I go to.

This got me thinking, what is the actual point of trying to get into a prestigious residency? (as far as I know, academic programs are more highly sought after compared to community hospitals, etc.). I understand the difference of trying to match into dermatology vs PMR, but I am personally only interested in matching into internal medicine. Not interested in any fellowship at this point, either. In this case, I am not convinced about why I should try to apply to competitive residencies come three years. Doesn't a more prestigious hospital just mean working in a more stressful environment setting that works you to the bone? More chances of exceeding 80 work-hour limits? Highly competitive residents and brutal faculty? Perhaps smaller pay because of so much competition for limited residency spots? (my local community internal residency program has average of $68,000 salary, 25 days vacation/sick leave; can't see this being beaten by more prominent programs).

Am I missing something here?

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[operaman]

Good question. Many reasons. I’ll list a few:

1) better fellowship options. If 5 years from now you find you want to specialize within IM, much harder to do that from a small unknown community program. I suppose this is arguably one of the biggest reasons people seek out top IM programs.

2) better training. Yes this can vary widely, but generally speaking you will see more interesting pathology at more prestigious places.

3) career connections. Harder to quantify as many jobs just want a warm body that’s board certified, but better jobs will care about where you trained. Some Patients may care about your medical school, but other docs will look at your residency. You also depend heavily on faculty connections when findings first jobs, and more known faculty can potentially open more doors.


I would say in general that 4 years is a long way off and it’s awfully early to be closing doors. You can still decide to train at a smaller community program later even if you’re competing for top academic ones. Much harder to go the other way. Plus you may hit IM in m3 and decide you hate it - happens all the time!

Keep your options open. Go to the best school you can get in to. With the SAVE plan and pslf, cost really isn’t much of an issue anymore unless your specific plans say otherwise.

 

[gutonc]

Not going to argue with you, since you make some good points. But a few counterpoints can't hurt.

Good question. Many reasons. I’ll list a few:

1) better fellowship options. If 5 years from now you find you want to specialize within IM, much harder to do that from a small unknown community program. I suppose this is arguably one of the biggest reasons people seek out top IM programs.

This is definitely true. A big name program will get your foot in the door even if you might not "deserve" to be there. If you have a career goal that involves basic/translational or high level clinical research (being primary PI on clinical trials) then a "big name" program both for residency and fellowship is the way to go. No question.

2) better training. Yes this can vary widely, but generally speaking you will see more interesting pathology at more prestigious places.

FWIW, I saw more crazy s*** in my first 6 months as a community hem/onc attending than in my "name brand" fellowship. The "big name" programs will definitely give you access to an African wildlife refuge worth of zebras, but if you're planning a more generalist career, then the bread and butter is what you need and you're more likely to find that in non-quaternary care settings. This is not to say that MGH, Hopkins and UCSF (as random examples) produce crap generalists, just that they produce a lot more great super sub-specialists than generalists.

3) career connections. Harder to quantify as many jobs just want a warm body that’s board certified, but better jobs will care about where you trained. Some Patients may care about your medical school, but other docs will look at your residency. You also depend heavily on faculty connections when findings first jobs, and more known faculty can potentially open more doors.

Connections are about the people. If you want a career in a research focused academic setting, train in one. If you want a career in a community-based clinical setting, train in one. If you don't know which you want, it's easier to shift from the research focused academic setting to the community setting than the other way around (I know...I did it).

I would say in general that 4 years is a long way off and it’s awfully early to be closing doors. You can still decide to train at a smaller community program later even if you’re competing for top academic ones. Much harder to go the other way. Plus you may hit IM in m3 and decide you hate it - happens all the time!

Keep your options open. Go to the best school you can get in to. With the SAVE plan and pslf, cost really isn’t much of an issue anymore unless your specific plans say otherwise.

100% agree with this.

Also, remember that your time in training is temporary, but your training is forever. Is an extra $5K or 5 more days off a year nice to have? Absolutely. Should you choose your training program just for that? Absolutely not.

 

[GoSpursGo]

Reading your original thread, you're clearly fishing for reasons to keep your DO acceptance over the MD acceptance, and it largely seems to come down to the fact that it's really cold where you currently live and you want to move, and because you'd feel bad about having sent an LOI to the DO school.

If your desire to experience life in a new part of the country is really worth all of the negatives that come with the DO school noted in your original thread (beyond just MD being more competitive for residency options)... that is your prerogative and you certainly should live your life the way you want to live. But you're not going to find anyone telling you that it is a GOOD choice. Objectively speaking, there are many reasons why it is likely in your best interest to suck it up for 4 more years, get your MD, and then move for residency.

 

[xffan624]

I will be matriculating into medical school in the fall. I have another forum about my indecision of what medical school to attend (DO or MD), which has led me to deeply reflect on the consequences of my decision including what residencies I would be able to attend based on what school I go to.

This got me thinking, what is the actual point of trying to get into a prestigious residency? (as far as I know, academic programs are more highly sought after compared to community hospitals, etc.). I understand the difference of trying to match into dermatology vs PMR, but I am personally only interested in matching into internal medicine. Not interested in any fellowship at this point, either. In this case, I am not convinced about why I should try to apply to competitive residencies come three years. Doesn't a more prestigious hospital just mean working in a more stressful environment setting that works you to the bone? More chances of exceeding 80 work-hour limits? Highly competitive residents and brutal faculty? Perhaps smaller pay because of so much competition for limited residency spots? (my local community internal residency program has average of $68,000 salary, 25 days vacation/sick leave; can't see this being beaten by more prominent programs).

Am I missing something here?

An MD school just opens up more options in general overall. It's not just about going to a prestigious residency, it's about opening up more choices for you in whatever residency you decide to do. Even a less competitive residency will still have comparatively "prestigious" or desirable programs. Maybe you won't want those. Maybe one might be in a location or has a focus in something that interests and you'd like to keep your options open. Is it impossible to get to that program with a DO school? Maybe, maybe not. Is it easier with an MD school? Definitely yes. It's just hard to predict what you'll want this far in the future which is why most people will tell you to go with the MD and the easier path, but it's your life and your choice.

 

[comp1]

It would be better to focus on whether a more prestigious medical school matters than whether a prestigious residency matters if the OP is 4 years out from matriculating to a residency, prestigious or otherwise. I am ALL about choosing geography as the number one factor for residency in a given specialty. Its location is, more likely than not, where you will end up living for the rest of your life. Medical school is a very different. You do not know if you will like IM. Even if you've been practicing as a PA or NP for years and years (which seems unlikely), you still don't. I thought IM when I first started med school too and wow, did it really suck in terms of workload and general happiness. The good news about going to a more competitive medical school is that it opens opportunities for residencies. Even if you decide to stay with IM, you're more likely to be able to move to a geographical location you want to go to. That...may not be the case if you went to an extremely non-competitive medical school, although honestly with IM it might still be since there are just so many of those residencies. And let's say you actually do end up liking a very competitive residency, well...you've kind of blocked yourself there unless you really are at the very top of your class, but regardless you have made it harder. The trickle down effect is also going to affect fellowships. The situation in which I would choose geography for medical school is certainly not related to weather. You would choose geography if you are going to have large amounts of extended family immediately available there that are going to be supportive on a regular basis during medical school. This may or may not even be possible at a DO school since if I recall a lot of them send their 3rd and 4th years all over to complete their clerkships.

 

[dozitgetchahi]

Reading your original thread, you're clearly fishing for reasons to keep your DO acceptance over the MD acceptance, and it largely seems to come down to the fact that it's really cold where you currently live and you want to move, and because you'd feel bad about having sent an LOI to the DO school.

If your desire to experience life in a new part of the country is really worth all of the negatives that come with the DO school noted in your original thread (beyond just MD being more competitive for residency options)... that is your prerogative and you certainly should live your life the way you want to live. But you're not going to find anyone telling you that it is a GOOD choice. Objectively speaking, there are many reasons why it is likely in your best interest to suck it up for 4 more years, get your MD, and then move for residency.

I’m a DO who has done well for himself - trained at big places in a good subspecialty, and now has a very good job in that subspecialty. You can definitely do well as a DO. That said, my advice is that if you have an MD acceptance, go to MD school. Being an MD can open doors for you that are still difficult/impossible to open as a DO, and “DO bias” is still a thing out there at some elite places even for jobs (although this is mostly in academia, and is slowly changing). MD schools tend to do a better job of ensuring that their 3rd/4th year rotations are good quality, too. And nobody will care if you sent an LOI to a DO school or not. I would not let that figure into your thinking at all.

 

[IonClaws]

Probably. Said residencies likely have good fellowship placements BECAUSE of the residents they select, not because they themselves "cause" the good placements. While prestigious names will never hurt and likely help, overall it's selection bias, IMO.

 

[djo208]

The prestige of a school or residency program is neither useless nor everything. I am sure there are deeply flawed prestigious programs and excellent programs that are less prestigious. I have colleagues from both prestigious programs and less well-known programs who work at the same institution as myself, including both MDs and DOs. It neither makes nor breaks; it can be done. What I think is true is that having a more prestigious program on your resume does FACILITATE getting to the next step in your career with more choices or being more readily considered for some jobs, if only because it is a truism that prestige inherently carries social cache. If you hope to attain the residency or fellowship OF YOUR CHOICE, then prestige matters. If you simply want to be a good doctor practicing good medicine without respect to geography or other concerns, then prestige will matter less. It is nice to have choices, but simply being a good clinician is a valuable and sadly sometimes undervalued skill that holds its own prestige for those who can recognize it.

 

[voxveritatisetlucis]

Probably depends on whether you want a prestigious fellowship and or academic career

 

[DocWinter]

I've seen people come from lowly backgrounds go up into high positions later in career. And people who went to prestigious universities practice in the middle of nowhere.

I went to a DO school intentionally. Went to a community teaching program intentionally. I've worked at a top five University prior to med school and as a resident had a badge and privileges at a prominent, world renown University hospital.

I however had no interest in academic medicine and returned to my intended area to practice in a smaller community. I make in the 80 to 90th percentile and have an excellent quality of life.

The point above holds that you likely have better opportunity for fellowship at a more prominently known program. But if you don't intend to do that, it's likely unnecessary.

 

[dozitgetchahi]

FWIW, I saw more crazy s*** in my first 6 months as a community hem/onc attending than in my "name brand" fellowship. The "big name" programs will definitely give you access to an African wildlife refuge worth of zebras, but if you're planning a more generalist career, then the bread and butter is what you need and you're more likely to find that in non-quaternary care settings. This is not to say that MGH, Hopkins and UCSF (as random examples) produce crap generalists, just that they produce a lot more great super sub-specialists than generalists.

I agree with this.

I went to one of these “name brand” places (not one of the ones you listed, but a name everyone would recognize) for rheumatology fellowship. And I completely agree that there was way too much focus on esoteric illnesses and too little focus on bread and butter. Their philosophy went something like “any program out there can show you the basics wrt managing bread and butter, but here we have lots of patients with rare, unusual, and exotic issues, so that’s what we’re going to teach you”. I guess they thought we were going to learn the rest by osmosis.

For instance, one “focus” within this department was vasculitis - so we saw lots and lots of vasculitis. No joke, we probably finished fellowship seeing more ANCA vasculitis than most rheumatologists will see in their entire careers. We spent time in afternoon clinics where every single patient had GPA, EGPA, MPA, etc - managing these patients was absolutely drilled into us by one of the more caustic attendings in the department. To this day, if I see one of these patients I know exactly what to do, step by step….

…which is great for the one time every 1-2 years I see one of these patients out in the wild. We also saw lots of rare varieties of dermatomyositis, anti synthetase syndrome etc. Again, when I encounter one of these patients, that’s great experience.

But RA? PsA? Y’know, the things I see 5-10 times each day in a community rheumatology clinic? We did not see nearly enough of these cases when I was a fellow, and when we did it wasn’t a typical “bread and butter” situation. It was an RA patient who had failed every single drug known to mankind, or a PsA patient who also had active hep C, or some other weird twist to a normal plot line for these diseases. So when I got out into community practice, I had to basically build an approach to treating basic inflammatory arthritis patients from the ground up - because I just didn’t do nearly enough of that as a fellow. IMO there is no excuse for an “elite program” to graduate people who feel uncomfortable treating basic bread and butter, but it happened. Even if you were going to go academic after going to one of these fellowships, you still need to have experience treating the basics.

So do I think a “highly regarded” residency or fellowship is important? Eh. It certainly does help if you want to be a hardcore academic. I thought it was an interesting experience to see what it was like at an elite place, with really smart attendings, etc etc. On the other hand, it was very stressful, with a lot of pressure to do research and be “perfect” day in and day out. Would I do it again? I don’t know. Knowing that I would head out into community practice, I may be inclined to choose a lower pressure, less “prestigious” place where I may have seen the full breadth of bread and butter and had a more pleasant experience.

 

[Apollyon]

For instance, one “focus” within this department was vasculitis - so we saw lots and lots of vasculitis. No joke, we probably finished fellowship seeing more ANCA vasculitis than most rheumatologists will see in their entire careers. We spent time in afternoon clinics where every single patient had GPA, EGPA, MPA, etc - managing these patients was absolutely drilled into us by one of the more caustic attendings in the department. To this day, if I see one of these patients I know exactly what to do, step by step….

This reminded me of the Duke PICU. Duke is a center for Pompe's disease. If you have McArdle's or Chédiak-Higashi, sorry dude, you're out of luck! But, Pompe? You're in!

 

[Gonio5]

Some prestigious residencies have better conferences, making the boards, particularly oral boards, easier to pass. Some prestigious residencies, however, have worse operating experience, but not all. The worse is a non-academic, non-operative residency program.