Choosing an IM program of a lesser reputation in exchange for better fit

[Pensivethinker]

So, I will say up front, I have been very lucky in the interviews I have gotten and I'm "stuck" in a very positive decision-making progress. I apologize for the vagueries, but I think the concepts of my situation are more important than the specific programs. So here goes.

I am deciding between two programs. Location is not a factor. Program one: One of the top programs, would open all doors, and would provide phenomenal training. During my interview day however, it felt like the program was fairly rigid, impersonal, and residents all graduated in a very specific mold. This mold allowed the residents to acquire any fellowships or jobs that they wanted. They have been slow to take up change because of their strong reputation. Very much felt like what made the program strong was more the residents than features unique to the program (as the program did not feel very different from many of the "middle-tier" places I have been). I have worked with residents from this institution during medical school, all of them were nice, some were extremely personable and others were more interested in just getting work done (ie a mixed bag). The PD was minimally involved in the interview day and the program is clearly run in a major part by the chief residents.

The second program is considered more of an "upper middle-tier" program. Many people graduate this program and go to great fellowships, but fewer to "top" fellowships like program one. I did an away rotation at this program and got along with most of the residents again and most were very personable. The program director at this program was very supportive, remembered me from my away rotation, and would clearly be a cornerstone of the program and my education. This program is much more innovative than program one and has created ways of tailoring your education more to your interests and felt less mold-like. Overall, the residents seemed a little happier here. There was less of an elitist and impersonal feel and more of a comfortability. Researchers seem more approachable in general than program one.

Personally, my goals are uncertain at this point. I am thinking about a competitive fellowship (program one does better for this but program two does well) with some research or general internal medicine (likely academic primary care) with a focus on research. I would be happy to match at either and have no disappointment either way. I think my initial feeling was better at program 2 as far as fit. But I worry that I would be giving up the opportunity to go to a place that opens all doors and sets everybody up for gauranteed success. Though I do wonder if the kinds of fellowships that people go to from program one are even the kinds I want to go to (not very clinically oriented, more research oriented). I have no doubt I would find my niche at program one, enjoy my experience, and end up wherever I want to eventually...it just might take a little longer to find this niche than at program 2. Just for more specificity, program 1 is in the top few in the country and program 2 is in the top 20.

My questions are these: Has anyone chosen a program of a lesser reputation because it felt like a better fit? Could you speak to how you made this decision and how it has turned out so far? Any regrets? I greatly appreciate any advice you all have, thanks!

---

Members don't see this ad.

 

[whoknows2012]

"Fit" and happiness will play a huge role in your success as you move forward. If you're miserable at program a then you may be less productive with research and do less to further your career than at program b. So long as program b won't be closing any doors I'd say go with where you'd be happier. Prestige and reputation of an IM program is important buts it's far from the end all be all. I'm sure you'll succeed and do excellent at both places as they sound like great places to train

 

[Lccjblu]

It doesn't sound as though Program 1 has deplorable conditions by any means, and as you said there were people you have worked with that you could imagine yourself getting along with. Sure the administration at program 1 may not be as likeable, but honestly you're in the trenches with your co-residents and not your PDs. I see my aPD maybe three times a year at best. If I were you, I would go to program 1 as long as you don't absolutely hate it. The reason is because that "big name" that "opens doors" for you will forever stick on your CV. The reputation associated with that medical center/training program is yours to lose. Fellowship will be easier to get into, changing jobs in the future will be easier to do. Especially with fellowships, if you are wanting to get into a competitive one such as cards, GI, or pulmCC, that reputable training program will add points on your application.

 

[Danbo1957]

"Better fit."

Get into the best kindergarten, elementary school, high school, college, masters program, PhD program, medical school, residency, and fellowship. Period.

 

[ArkansasMed]

I would argue that you probably should choose reputation and proven track record for success, in this case program 1. Going to a top program has its huge benefits. You will always have that name on your CV, you will be in touch with academic leaders in their field and your co-residents will stimulate you to be better. Most of the top programs in medicine except for one are such because they are extremely clinically rigorous and prepare you to handle anything. Only a handful of programs in the country are truly resident run, have high volumes, get a ton of sick admissions/transfers and have the academic resources outside the hospital system. Fellowships over the years realize this and take those residents partially because of their reputation but also because they have a high probability to succeed. A common theme I hear from my co-residents who matched into fellowship and are applying for jobs is that they were highly sought out because they had gone through a very rigorous training program and historically, those do well in practice. Everyone in my program matched either at top choices (reputation or location based per individual). You should use residency as 3 years to make yourself as clinically excellent as possible. You will have time for research/will have the time to meet the right people if you ask around early. The same goes for year 1 of fellowship. After that, use fellowship to develop your extensive research background/other academic interests.

More food for thought, the probability of you being able to choose where you will attend after fellowship probably drops to a noticeable degree the lesser the program is ranked. I have friends at top programs who just pick where they want to attend in high demand fellowships. I have other friends who spend a year out of residency to match anywhere in the country in the field they want to match into. You'll find the same phenomenon with medical school. Look at the match list of Penn medical students over the years compared to say most state schools. You cannot tell me that all Penn medical students are as strong as the top candidates at state schools, hence proving reputation matters.

To be fair, if you are convinced the style of that institution is not for you, then I would not attend.

Best of luck.

 

[Pseudopseudonym]

Agree with everyone else here. As someone who is finishing at a "top reputation" program, I think 90% of your happiness and success will be based on the location and the people (i.e. the fit). Forget about rankings and if you chose based on those, you'll enjoy residency. You're going to get great training no matter where you go.

Good luck!

 

[bashwell]

This would matter more if you were comparing a top program where you didn't fit in vs a bottom ranked program where you felt you fit in. But you're comparing a top program with a just below top program (upper middle tier program). I'd go with good fit at an almost top program (upper middle tier program) vs a top program where you don't feel you fit in well.

 

[loeffy]

I went through nearly the exact same thing for my IM rank list and I too was interested in a competitive subspecialty. I ranked the more reputable program higher but ended up at the program that was a better fit, and in the end I was very happy where I ended up and it still got me to where I eventually wanted to be for fellowship. If I had ended up at the reputable program, I think I'd still would have been happy but it's hard to say how fellowship would have worked out, it may have been easier or I could be worse off, it's a bit of a crapshoot with fellowship. The one thing I will add though is that your feeling and impression on interview day may not be an accurate assessment of the program, unfortunately it's all applicants have to go off of. The culture and vibe can change quickly, leadership can change, chiefs and co-residents change each year, all of which can totally change the dynamic of the program. Additionally, what people say on interview day may not be entirely accurate or they may withhold some info that you may not realize until you get there, so it doesn't hurt to have a healthy skepticism or moderate expectations. I wouldn't worry about the types of places people match, the rep of the program will help either way. While fit is important, rep matters as well, especially for someone interested in fellowship. For you, the reputable program doesn't sound terrible and you said you'd be happy to match there, I'd rank it higher.

 

[buonassezia]

A friend and I each made a similar choice to the one you have outlined. We each ended up at our "better fit," lesser-ranked programs. Absolutely no regrets.

Residency is a huge challenge wherever you go, and is a more dynamic learning environment than the classroom or med school. Wherever you go, you will be able to find excellent mentors, researchers, etc. At academic centers, there is no shortage of these. What does your program prioritize? What is the culture, really? Do they value you and your education? How are your working relationships with peers and senior residents? These things are the meat of your day-to-day, and matter a tremendous amount more than any numerical, fairly imprecise ranking does when it comes to residency. You are in a new phase of life now. There is not the same meaningful U.S. News & World Report for residency like there was for college. Your decisions will need to incorporate new multidimensional complexity. Good luck.

 

[portal2]

One thing I learned on the trail last year was how the culture of the place was. Ask about it. What's the culture of the medicine department? Are people smiling? Approachable? Is it a place you could see yourself not dreading to go to in the morning? That stuff is way more important than prestige.