Can't decide on my #1

[snappy]

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Hi guys. So here's my deal. I am deciding between two programs for the #1 spot on my rank list. One of the programs, we'll call it Big Name, is a large, highly academic program that is ranked near the top for this particular specialty. Loved the residents I met on the interview day but did get the impression that they are overworked overachievers who thrive on knowing they are the best, even if the residency itself is not a super happy place. It didn't seem malignant, but did have the negatives of being overly academic - such that it was fellow-driven and even senior residents sometimes got the shaft in terms of procedures and autonomy. But, coming out of there, you can match anywhere in anything. They absolutely dominate the fellowship match. And having that name on your CV for the rest of your life will certainly open any door you need to open.

The other program is a smaller, also academic program, we'll call it Happy Place, where the residents are incredibly, incredibly happy. This program is probably considered a "high second tier" program. Not as tops as Big Name, but still up there, and the residents do reasonably well in the fellowship match, even if they don't light it up the way Big Name's do. The program has fewer fellows, so the residents are more autonomous. The nice thing is, since it's a smaller program, you get all the benefits of a more community-style atmosphere (knowing your attendings super well, knowing the nurses and ancillary staff to grease the wheels when you need favors, a friendly hospital environment) while not losing any of the academics (great research opportunities, many grads go on to fellowship.) And the most striking thing about it is, the residents there are so happy, it's like they're on crack. But the good kind of crack that makes you smart and productive.

So from reading my own descriptions above, it seems like I should pick Happy Place, right? But this is where I need your help. It is almost like I have two gut feelings, one that says I would be happier for residency at Happy, and the other that says I will be happier in life from Big Name, because it will be easier for me to get the fellowship I want and to set up my career the way I want. As much as I am tempted to rank Happy Place #1, part of me would always wonder "what if..." I almost think I would be happier going to Happy Place if I DID rank it #2 and failed to match at Big Name. It would feel like it was where I was meant to be and that I had not passed over any other opportunities for the sake of wanting to be a happy crack resident.

So, to date, I've kept Big Name on top of my list. I would be thrilled to match at either. I am just wondering if I am choosing for the wrong reasons. Just to give you some more background, both locations are dead equal for me in terms of wanting to live there, and although the residents at Happy were maybe a little nicer, I probably fit in better with the ones at Big Name. So those are the pretty equal intangibles that I would try to use to tie-break, in case you were wondering.

 

[pmpkn219]

To me, it would be place #2, by far. BUT I have no intentions of being super-academic/ivory-tower... I'm not even sure I'll do a fellowship. It sounds like you're definitely leaning to a fellowship (that could change, of course, but also may not)... in that case the higher prestige of Big Name could help.

Then again I've heard time and again that at a really Good program, which it sounds like Happy is, not being super Big shouldn't hurt your fellowship chances. You'd know your attendings better, so theoretically they could write you better letters, or involve you more in original research... both things which would go a long way in your fellow apps, I'd imagine?

It does seem to be a tough call for you. Your idea of ranking Big 1st, and if you get Happy then it was fate... sounds like something I would feel inclined to do! I kinda like that the Match takes things a bit out of our hands, so you can do a little less "what if..." afterwards... the computer did it, albeit with your guidance.

The question I think you need to ask is this: were the residents so over-achieving and hardcore that it would wear you down the next 3-4 years? You said it wasn't outright malignant, and that you maybe identified more with the Big Name residents. So maybe you wouldn't be unhappy at the non-Happy Place 😉 Can you/did you do a second look to get a better feel for resident interactions?

If you think you could be ok in that environment, I would rank Big #1 and see where the Match/fate lands you.

 

[Samoa]

You said yourself that you feel you'd fit in better at Big Name, wouldn't mind being at Happy if you failed to match at Big Name, but that if you rank Happy first, you'd always wonder if you were selling yourself short.

If being reasonably happy in residency and having the freedom to largely write your own ticket afterward is more important to you than being absolutely crack-happy in residency but not as able to write your own ticket afterward, you should go with Big Name as your #1. It's a question of immediate vs delayed gratification.

 

[smq123]

One of the programs, we'll call it Big Name, is a large, highly academic program that is ranked near the top for this particular specialty. Loved the residents I met on the interview day but did get the impression that they are overworked overachievers who thrive on knowing they are the best, even if the residency itself is not a super happy place. It didn't seem malignant, but did have the negatives of being overly academic - such that it was fellow-driven and even senior residents sometimes got the shaft in terms of procedures and autonomy. But, coming out of there, you can match anywhere in anything. They absolutely dominate the fellowship match.

It didn't seem malignant....but that doesn't really answer the question of IS it malignant?

The thing about the interview day that I think is hardest on everyone applying is that it's literally a quick 12 hour exposure to a place. It's relatively easy to pretend to be shiny, relatively happy, and pleasant for a few hours (particularly when food and drink is being distributed). It's another to be shiny, relatively happy, and pleasant when the patients are pouring in and the residents are getting slammed.

Is there any way of determining whether or not the place is malignant? Maybe a second look, or talking to students from that school who have rotated there?

 

[Law2Doc]

... or talking to students from that school who have rotated there?

I don't know that a second look is going to be any better insight than an interview day -- you still see what the program chooses to show you. But talking to alumni from your school who are residents, or a mentor who knows some of the people there, or even a resident who has offered up his/her email, might give you more insight. Everybody in the specialty will know which places have the malignant reputations, but the programs for obvious reasons won't advertise this, and will try to put forward residents and interviewers who will say nice things about the program. Same goes for the second look visits -- you will be rounding with a team working under a dynamic, teaching oriented attending, not the SOB resident hating bastard you could end up with in July. So you probably see how well a program hides its dirty laundry rather than the laundry itself. You only find out about the laundry by talking candidly to someone outside of the direction of the program.

 

[snappy]

Thanks everyone for the thoughtful responses. This Big Name program does have a reputation for malignancy in the field, but it's hard to see whether people are kind of bad-mouthing it because it's, you know, the top program in the field, and therefore everyone assumes it MUST be malignant. I have heard both "don't go there, you'll be miserable" and "don't believe the rumors" (from people who are not associated with the program in either case.) I do have a close friend who is a resident in a different program at that hospital who seems to think that the residents in my program are overworked, but he doesn't know much else and isn't good friends with anyone more closely affiliated with the department.

I feel like if I do go there, it will be with the expectation that this the residency years will be brutal but worthwhile. I am just not sure *how* worthwhile it would have to be to balance out the brutality, which may or may not just be hearsay from people. It is probably getting to be a little too late for a second look but I will try to talk more to people who know residents in the program re: how things really are at Big Name Hospital.

 

[Abram Hoffer]

Just be happy. 😀

 

[dragonfly99]

Some degree of malignancy goes with a lot of the "top" programs that have great fellowship matches. If it's IM and you want to do something like GI or cards, I think it will probably benefit you to match at the highest-tier place you can get into. If you just want to do endocrine or renal, it probably doesn't matter.

 

[SocialistMD]

...although the residents at Happy were maybe a little nicer, I probably fit in better with the ones at Big Name...

Big Name...residents...are overworked overachievers who thrive on knowing they are the best...
Happy Place...residents are incredibly, incredibly happy...

In my opinion, this should be your top priority with all other things being "equal." If you are the type of person who is happiest as an overworked overachiever who thrives on knowing you are the best, you probably wouldn't be happy at Happy Place, as your coresidents' attitudes and views on life likely will not mirror your own. You would also screw up the chemistry of Happy Place if you brought your overachiever attitude to their environment, and they would hate you for your know it all persona.

Me, I like my Happy Place with Julie Bowen wearing a white negligee and carrying two full pitchers of beer...

 

[John Deere Gree]

Me, I like my Happy Place with Julie Bowen wearing a white negligee and carrying two full pitchers of beer...

WOW! A fan of Julie Bowen. I haven't seen or heard much about her since her stint on Ed (on NBC) as Ms. Vessey.

 

[SocialistMD]

WOW! A fan of Julie Bowen. I haven't seen or heard much about her since her stint on Ed (on NBC) as Ms. Vessey.

While I am a fan of Julie Bowen, it was more a reference to Happy Gilmore when he's trying to find his "happy place," as that is what immediately came to mind when reading this thread.

 

[snappy]

You would also screw up the chemistry of Happy Place if you brought your overachiever attitude to their environment, and they would hate you for your know it all persona.

Uh, I wasn't saying that the residents at Big Name are know-it-alls, merely that they seem to be very hardworking. The part of me that feels I fit in better with them is the part of me that is more of a wiseass, like the Big Name residents were, than a nicey-nicey type like the residents at Happy were.

 

[SocialistMD]

Uh, I wasn't saying that the residents at Big Name are know-it-alls, merely that they seem to be very hardworking. The part of me that feels I fit in better with them is the part of me that is more of a wiseass, like the Big Name residents were, than a nicey-nicey type like the residents at Happy were.

Sorry. I didn't really mean "know it all," I was just struggling to find the adjective form of "like to know they are the best." Again, you should try to go to the program where you would be around people like you, particularly if you are a wiseass, as nicey-nicey people often have thin skin and wouldn't appreciate your humor, benign as its intentions may be (And I'm speaking from personal experience on this one 🙄).

 

[snappy]

Sorry. I didn't really mean "know it all," I was just struggling to find the adjective form of "like to know they are the best." Again, you should try to go to the program where you would be around people like you, particularly if you are a wiseass, as nicey-nicey people often have thin skin and wouldn't appreciate your humor, benign as its intentions may be (And I'm speaking from personal experience on this one 🙄).

Thanks, I understand and agree - have also been in situations where people do not appreciate my wisecracks 🙂

 

[BlondeDocteur]

In this thread you seem defensive of Big Name (literally defending it against slurs). You seem to identify with Big Name. I think your choice is made, and you know it.

I'm fond of the coin toss method myself: pick a coin, standard US mint, assign heads to Big Name and tails to Happy Place. Toss it in the air. Catch. Place one hand over. Flip coin.

Before looking at the coin, which one were you hoping it would be?

 

[Doctor Bob]

I'm fond of the coin toss method myself: pick a coin, standard US mint, assign heads to Big Name and tails to Happy Place. Toss it in the air. Catch. Place one hand over. Flip coin.

Err.... is it bad that I did this?

And rather than start a new thread with a similar question, I'll just ask it here.

So after weeks of making spreadsheets, comparing benefits, curriculae, the surrounding community, etc, I'm still no closer to differentiating my top programs. Essentially I'm at the point where I'd rather just rank them all #1 and let the match sort it out for me. Maybe that's why I turned to coin flipping.

Program 1: Moderate sized city, rotations at seven different hospitals over the course of the residency (from small community hospitals to big level 1 trauma centers). Old established program. Average salary and average benefit package.

Program 2: Small middle of nowhere town, but large tertiary referrral center, level 1 trauma center (dunno how that happened). Old established program, lots of associated residency programs. Best salary but so-so benefit package.

Program 3: Moderate sized city, rotations at two community hospitals (level 2 trauma centers), program only 2 years old. Only one other residency program at the hospital so no overlap. Best benefit package except lowest salary.

They have equivalent curriculums, equal moonlighting opportunity, I got along well with the staff and residents at all three programs, I have no geographic ties to any of them, the atmosphere of the program (community vs big referral center) doesn't matter because I have a lot of military obligations after I finish so I don't really care if it points its residents towards academics or community medicine.

I had an easy time building my ROL from the bottom up, but when I hit the top 3-4, I stalled.

And my wife, in looking at the cities and what there is to do for her and our kids, came up with her own rankings independently and finally said "well, these are my top three favorite but I like them all about the same for different reasons" and they were the same 3 places.

sigh.

 

[LadyGrey]

Program 1: Moderate sized city, rotations at seven different hospitals over the course of the residency (from small community hospitals to big level 1 trauma centers). Old established program. Average salary and average benefit package.

7 hospitals sounds painful... so much time lost in mastering new computer systems, finding where stuff is, etc.

Program 2: Small middle of nowhere town, but large tertiary referrral center, level 1 trauma center (dunno how that happened). Old established program, lots of associated residency programs. Best salary but so-so benefit package.

This sounds pretty good.

Program 3: Moderate sized city, rotations at two community hospitals (level 2 trauma centers), program only 2 years old. Only one other residency program at the hospital so no overlap. Best benefit package except lowest salary.

What field is this? Because no few/no other residents would be a minus to me, but I know in family medicine it's seen as a good thing.

I'd rank them 2,3,1. Or 2,1,3 -- can't decide if the newness/ lack of other residents at number 3 is worse than having to bounce among 7 different hospitals.

Whee, this is so much easier when it's someone else's rank list. Now if only I could decide between my own 2 and 3...

 

[NotAProgDirector]

I'm fond of the coin toss method myself: pick a coin, standard US mint, assign heads to Big Name and tails to Happy Place. Toss it in the air. Catch. Place one hand over. Flip coin.

Err.... is it bad that I did this?

Yes, because you missed the VITAL last step (which makes the process quite useful):

Before looking at the coin, which one were you hoping it would be?

 

[dragonfly99]

7 different hospitals sounds like too many...it'll be a PIA driving all over town, and also having to deal with different nursing, lab and computer systems (especially the latter). Imagine having 10 different computer passwords (assume one password to log in the computer, and sometimes there's another one to log into labs or a subsection/software on the computer).

 

[Doctor Bob]

What field is this? Because no few/no other residents would be a minus to me, but I know in family medicine it's seen as a good thing.

It's EM. And for EM it seems like it would be a good thing... no surgery residents fighting for trauma procedures, or IM/CC residents taking ICU procedures, etc.

7 different hospitals sounds like too many...it'll be a PIA driving all over town, and also having to deal with different nursing, lab and computer systems (especially the latter). Imagine having 10 different computer passwords (assume one password to log in the computer, and sometimes there's another one to log into labs or a subsection/software on the computer).

Yea... that does strike me as a downside. Hmmm...

...because you missed the VITAL last step (which makes the process quite useful): Before looking at the coin, which one were you hoping it would be?

I wanted it to land on its side. 😀

 

[LadyGrey]

It's EM. And for EM it seems like it would be a good thing... no surgery residents fighting for trauma procedures, or IM/CC residents taking ICU procedures, etc.

I'm also going into EM -- it would be interesting to pose this question in the EM forum and see what responses you get, but IMHO a place with only one other residency would be suboptimal. Especially when it's a very new program -- the overall academic structure just isn't there, and attendings won't be used to dealing with residents.

My experience is based on having done some 3rd year rotations at a community hospital with only family medicine residents, and while it may've been good for their inpatient medicine months that there were no IM residents around (though even that is debatable), it definitely looked like a negative in their off-service months. The residents seemed to be treated almost like medical students more than as real members of a team.

The surgery thing is a real concern. But as far as unit rotations, most EM residents that I talked to on interview days said that they got a lot of respect from the IM residents for their procedural competence and were sought out to do things rather than being in a power struggle. I'm sure IM folks need to get a certain minimum number of some procedures but beyond that I don't think they're into fighting over them.

 

[snappy]

I'm fond of the coin toss method myself: pick a coin, standard US mint, assign heads to Big Name and tails to Happy Place. Toss it in the air. Catch. Place one hand over. Flip coin.

Before looking at the coin, which one were you hoping it would be?

I tried this and didn't have a clear preference before I flipped the coin over! But I think you're right... I kinda want to go big and all out with Big Name even if part of me thinks it's a dangerous idea... 🙂

 

[Doctor Bob]

I tried this and didn't have a clear preference before I flipped the coin over!

Just make sure you don't use one of the state quarters that corresponds to the state one of your programs is in. That might bias your subconscious

Use something nice and generic, like a buffalo head nickel... unless one of the programs is in upstate New York...

 

[snappy]

Just make sure you don't use one of the state quarters that corresponds to the state one of your programs is in. That might bias your subconscious

Use something nice and generic, like a buffalo head nickel... unless one of the programs is in upstate New York...

Hahaha 😀 They're in the same state so no issues there. I just don't have a gut feeling!!

 

[John Deere Gree]

Just follow your heart. That's what I do.

 

[guitarguy09]

Some degree of malignancy goes with a lot of the "top" programs that have great fellowship matches. If it's IM and you want to do something like GI or cards, I think it will probably benefit you to match at the highest-tier place you can get into. If you just want to do endocrine or renal, it probably doesn't matter.

The other option is to make sure that both programs offer a fellowship position in your chosen field (because programs often take quite a few of "their own" residents)... it's much "safer" to take someone they know than to gamble on a random person with an unknown work ethic / personality. That being said, I think location needs to play a role in your decision also. Proximity to friends/family, etc. It's important to think about your life outside of each residency program too (for the little time we actually get off... ).

 

[Zock]

It is almost like I have two gut feelings, one that says I would be happier for residency at Happy, and the other that says I will be happier in life from Big Name, because it will be easier for me to get the fellowship I want and to set up my career the way I want. As much as I am tempted to rank Happy Place #1, part of me would always wonder "what if..." I almost think I would be happier going to Happy Place if I DID rank it #2 and failed to match at Big Name. It would feel like it was where I was meant to be and that I had not passed over any other opportunities for the sake of wanting to be a happy crack resident.

So, to date, I've kept Big Name on top of my list. I would be thrilled to match at either. I am just wondering if I am choosing for the wrong reasons.

I had the same dilemma as the OP. I feel like I could have written the exact same thing as well as the comments about immediate vs. delayed gratification. I also came to the same conclusion of ranking the Big Name #1, and leaving it up to fate on whether or not I'd get into my Happy Place which I ranked #2.

The hard part is now...waiting to see how it all falls out. I'm constantly kicking myself for not ranking my happy place #1, and I'm actually terrified that I will be one of the 50% of people who get's their #1 choice on the ROL. How messed up is that?

So I totally understand, OP. I hope things work out for you, and no matter where you wind up it will turn into your real happy place!

 

[snappy]

I had the same dilemma as the OP. I feel like I could have written the exact same thing as well as the comments about immediate vs. delayed gratification. I also came to the same conclusion of ranking the Big Name #1, and leaving it up to fate on whether or not I'd get into my Happy Place which I ranked #2.

The hard part is now...waiting to see how it all falls out. I'm constantly kicking myself for not ranking my happy place #1, and I'm actually terrified that I will be one of the 50% of people who get's their #1 choice on the ROL. How messed up is that?

So I totally understand, OP. I hope things work out for you, and no matter where you wind up it will turn into your real happy place!

Thanks Zock, I hope the same for you! I ended up rankig Big Name #1 too, but did so after trying to keep Happy in the top spot for the last few days. About an hour before rank lists were due, I felt sick to my stomach and knew that it was because I really wanted to rank Big #1. There are a million logical reasons not to, but it felt like the right choice for me in my gut. It took until the 11th hour to have a gut feelings but I finally had one!

I hope you end up at the right place for you and urge you to not feel any regrets. We may think we know how one place is over the other, but our limited exposure to each program means we can never really know what life would be like there until we live it. We'll only live ONE program and won't have anything to compare it to, and unless the program TOTALLY blows, we'll find ways to be happy and make the most of the opportunities. So I don't have any regrets, would be thrilled to match at either, would probably feel a little bit of relief at "ooooh, that woulda been so hard, yay I matched at Happy Place!" if I matched #2 but would feel more excited and challenged about matching #1. It's all a balance. It'll work out for both of us! good luck!