Cleveland Clinic Reputation

[imdoc]

How would you rank the reputation of Cleveland Clinic in terms of the IM residency? Is it a "first tier"? Would you rank it higher than university based programs? Is it up there with Cornell, Columbia, etc.?

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[Pinky]

No. It is not a first tier program. It is definitely NOT up there with Columbia, Cornell. Where would I rank it?

Would I rank it higher than university based programs? It depends which university based program we're talking about. U of Chicago, Hopkins, Wash U? Definitely not. Loyola, UT Houston, probably. CCF is as good as some university based programs. I'd probably rank CCF as a mid-tier program.

 

[imdoc]

Would you rank it higher than University of Miami, University of Florida, SUNY Downstate , SUNY Stony Brook?

 

[imdoc]

anymore input?

 

[Maui]

Just wondering where you got that 3 out of 12 info, and would you also know how other prestigious programs fare in the Cards match?

 

[smackdaddy]

9/12 sounds pretty good. especially considering several were probably international grads. and others probably had geographic or personal reasons why they might not match.

it is the most competitive subspecialty of medicine. it is full of people who have their own large egos and don't think that the ccf is the be all and end all of cardiology.

you would not believe the caliber of applicants to cardiology today. the people who aren't even invited for interviews are light years ahead of people they begged to do the fellowship 8 years ago.

 

[Maui]

Ten residents who graduated from CCF last year are actually going into Cards fellowships this year in various hospitals, and 19 out of 47 residents are staying on at CCF as hospitalists, fellows, chief residents, or staff physicians...hey that sounds pretty good to me. Their ABIM pass rate is 94, and based on just that, it couldn't be a lower-tier program. The interns did seem like they were a little tired and probably doing a lot of work, but with the following points in mind:

-research opportunity
-opportunity to be mentored by or work with some of the brightest minds in medicine
-new medical school in connection with Case Western, for clinician-researchers, opening up in 2004 (which means a more academic slant and a wider pool of teaching staff, from Case Western and recruited from other universities, and maybe bringing with it the much needed rep boost)

CCF is going to be an exciting place to be doing residency in the next few years...

 

[GenMed]

Originally posted by smackdaddy
you would not believe the caliber of applicants to cardiology today. the people who aren't even invited for interviews are light years ahead of people they begged to do the fellowship 8 years ago.

I know that there is no "typical" applicant, but can someone knowledgable about this paint a picture of your average successful cards fellowship applicant who gets into a top-flight program? How many (if any) papers to his name? Do the ABIM board scores count? Do you even get to know what they are? How about USMLEs?

 

[smackdaddy]

some have papers, some don't. but if you have them, it sets you apart from the pool. there are different levels, even among publications, first author, fifth author. quality of journal, review article or case report or whatever.

abim-most people apply during 2nd year of residency so they are still two years from taking the abim. traditional residency to fellowship people will take the abim during fellowship

they do get your usmle's.

what do you want to hear?
the typical applicant is a successful internal medicine resident or practitioner. it is understood that they are outstanding clinically, and no program got famous for admitting a clinically astute resident. it is expected that you will have outstanding letters of recommendation, and not just letters that say during the two weeks i worked with the individual, he/she seemed to be able to take care of patients.
the way to get ahead is the same as any ultra competitive field.
ymmv

 

[impatiently waiting]

I've heard they don't take a lot of their own residents for the cardiology program, but i don't have numbers on that, it's just hearsay.

Anyway I did a couple rotations there, one of which was in IM. Yes there is a lot of research there, but I just didn't like the atmosphere. It felt very competetive, and while the residents talked to each other, they didn't really seem to be much more than just co-workers. In other words, some hospitals i have been at you can see a good comraderie and relationship between residents. I didn't really see that up there. I don't know if it was because a lot of the residents are IMGs or if it was just that class of residents. I also felt like the attendings made it a formal atmosphere more than other places I have been. just my experiences though -

 

[smackdaddy]

i'm curious what you think an appropriate # of cards fellowships are for ccf residents. you already have stated that you don't think the residency is that strong. so should weaker medical students who become weak residents but want to go to cardiology just go to cleveland clinic and be guaranteed a fellowship based on the reputation of the division?
it is the most competitive subspecialty in medicine. there are hundreds of great applicants from outside ccf. and they don't take their own, unlike most programs, which increases the likelihood of people not finding positions.

and again, there are alot of other reasons why someone might not match. personal reasons limiting their finances, ability to apply/interview, visa issues.

 

[task]

I did a CICU rotation at CCF as a 4th year medical student with Eric Topol and Steven Nissen. There are 12 General Cardiology fellows there each year. The year I was there, one fellow came from CCF. They seem to take one fellow from their own IM program every year or every other year. One of my good friends and his wife both finished Cards fellowship there, and pretty much validate this trend. I train at Parkland for IM, my friend trained at Stanford for IM, and his wife trained at Penn for IM. We all agree that the IM residents there, while well intentioned and bright, are not at a great place to be an IM resident. The bottom line is that people go to the CCF for subspecialty medical and surgical care, not to have some general medicine resident treat them. Your autonomy is limited. I remember seeing 2nd and 3rd year residents there struggling with basic procedures like A-lines and central lines that I became proficient at within my first month of internship. Most of the time, they call anesthesia to intubate the patient because that's what folks in the privatee world with real insurance expect. They have a lot of smart IMGs there, but unfortunately, people talk about programs based on the #s of IMGs there in term of "is this a good program or not". I think if you want to get into Cards fellowship, you would be better served going to as good an academic medical center as you can get into.

One other thing. I would argue that Cards is no longer the most competitive fellowship to get into. Based on pure #s, Allergy and Immunology, with only SIXTY spots nationally, is easily the most competitive. And before you say "well the smartest people go into Cards" I would seriously bet against that. The competition over the last two years for A&I has ramped up amazingly, and now the brightest of the bright are entering the field -- lured by a great lifestyle and $300-400k per year salaries after a few years in practice.

Of the "glamour" specialties, I would argue that GI is more competitive than Cards. Only 200-250 or so spots for GI compared to 800 or more for Cards. As good money as Cards. Somewhat better lifestyle. As for candidates, GI attracts the same personalities as Cards does -- procedure oriented, tangible end-point types. There are more people who originally thought about Cards who are now going into GI than vice versa. The quality of people applying to GI is out of control, with many programs screening people based on board scores and CV before they even let you send an application. You can match into Cards if you are a US medical grad and apply and rank intelligently (a whole range of programs). With GI being a rolling admission thing, there is no such guarantee.

 

[Maui]

Doesn't anyone have anything positive to say about their experience at CCF in this forum? I wonder if the residents there feel the same way as the "observers". By the way, I am an IMG and have finished internal medicine residency in my home country, where IM training is much more clinical as opposed to technology-dependent. I am starting IM in CCF this July, and am hoping to prove all the comments regarding the relative strength of the program wrong.

I actually find it hard to believe that one cannot get a good general IM training at this place, considering that the hospital is right smack in the middle of Cleveland, and would thus get not only complex tertiary referrals, but also the bread and butter cases from the area. Anyway, I guess I'll be able to tell you guys more 6 months from now. Having finished IM already elsewhere, my objectives for this repeat residency would be quite different from those who are just entering the specialty. I believe I will be able to fulfill those goals in CCF.

I find it interesting, though, that the comments againtst CCF seem pretty strong. I am sure there are a lot of lousy programs out there, but people seem to find the hospital vs. program rep of CCF a particularly juicy topic.

 

[smackdaddy]

Originally posted by task
I did a CICU rotation at CCF as a 4th year medical student with Eric Topol and Steven Nissen. There are 12 General Cardiology fellows there each year. The year I was there, one fellow came from CCF. They seem to take one fellow from their own IM program every year or every other year. One of my good friends and his wife both finished Cards fellowship there, and pretty much validate this trend. I train at Parkland for IM, my friend trained at Stanford for IM, and his wife trained at Penn for IM. We all agree that the IM residents there, while well intentioned and bright, are not at a great place to be an IM resident. The bottom line is that people go to the CCF for subspecialty medical and surgical care, not to have some general medicine resident treat them. Your autonomy is limited. I remember seeing 2nd and 3rd year residents there struggling with basic procedures like A-lines and central lines that I became proficient at within my first month of internship. Most of the time, they call anesthesia to intubate the patient because that's what folks in the privatee world with real insurance expect. They have a lot of smart IMGs there, but unfortunately, people talk about programs based on the #s of IMGs there in term of "is this a good program or not". I think if you want to get into Cards fellowship, you would be better served going to as good an academic medical center as you can get into.

One other thing. I would argue that Cards is no longer the most competitive fellowship to get into. Based on pure #s, Allergy and Immunology, with only SIXTY spots nationally, is easily the most competitive. And before you say "well the smartest people go into Cards" I would seriously bet against that. The competition over the last two years for A&I has ramped up amazingly, and now the brightest of the bright are entering the field -- lured by a great lifestyle and $300-400k per year salaries after a few years in practice.

Of the "glamour" specialties, I would argue that GI is more competitive than Cards. Only 200-250 or so spots for GI compared to 800 or more for Cards. As good money as Cards. Somewhat better lifestyle. As for candidates, GI attracts the same personalities as Cards does -- procedure oriented, tangible end-point types. There are more people who originally thought about Cards who are now going into GI than vice versa. The quality of people applying to GI is out of control, with many programs screening people based on board scores and CV before they even let you send an application. You can match into Cards if you are a US medical grad and apply and rank intelligently (a whole range of programs). With GI being a rolling admission thing, there is no such guarantee.

some of your facts are incorrect.
cards has almost 600 positions not 800.
and the money in gi while fantastic, has yet to reach that of cardiology in any survey i have seen. certainly in some locations, gastroenterologists will make more than cardiologists.
furthermore, it is clearly incorrect to say that us medical grads will obtain a cardiology position merely by applying and ranking carefully.
how many people apply to allergy and immunology fellowships? i assume when you say it is the most competitive you mean not just that they have 60 slots but they must have a significant # of competitive applicants.
interesting that you would say that gi being not part of the match would reduce your chances of obtaining a position. certainly it is ultra competitive now, but i am not clear why rolling admissions reduce your chances of securing a spot if you are a good candidate. it reduces your chances if you apply poorly, without question. but the same could be said of any specialty. not being in the match offers considerable advantages to applicants as well.

 

[smackdaddy]

task wrote
The bottom line is that people go to the CCF for subspecialty medical and surgical care, not to have some general medicine resident treat them. Your autonomy is limited. I remember seeing 2nd and 3rd year residents there struggling with basic procedures like A-lines and central lines that I became proficient at within my first month of internship. Most of the time, they call anesthesia to intubate the patient because that's what folks in the privatee world with real insurance expect.
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not picking on you, but just wondering if this is any different than northwestern or mayo or whatever pick your favorite private hospital?

 

[task]

Smackdaddy,

1. Salary surveys are at least 1-2 years behind the times. I think a more accurate barometer of what specialists make is to get information of what bread and butter activities reimburse. All procedures have taken a hit, but the bread and butter Cards procedures have taken a proportionately much greater hit than GI procedures have. For example, 2-3 years ago, a 2vessel PCI (PTCA c stent) paid $2-3000 depending where you live in the country. Now, the same case pays $700-800. That's one reason why not as many people are aggressively pursuing interventional fellowships. In the same period of time, reimbursement for a colonoscopy has remained pretty level. No doubt, Cardiologists make fantastic money, and it would be silly to say otherwise. When I say "as good money" I also mean that for the hours GI docs (which are very busy and long hours, don't get me wrong) they aren't always as bad as the typical Cardiologist's hours. And then, as you've said, there are GI docs who outearn Cardiologists anyway. Remember, salary surveys of Cardiologists are skewed in that interventionalists and EP guys tend to make more than diagnostic/non-interventionalists. If you look at surveys breaking the two apart, you do see a distinct (almost $100,000) difference between the two.

2. If you say 600 spots in Cards, OK. The latest survey I saw listed almost 800 spots, with plans by the ACC to accredit more positions given the demand.

3. The collapse of the match in GI has made the already competitive situation even worse, mainly for candidates. The programs have it great. What happens is that programs all want the most competitive of the competitive, so they all scramble to offer positions to the people they want early on in the process. Candidates are screwed because they feel compelled to take an offer early on because they can't tell a program "thanks for the offer, but I'm gonna see where else I get in before telling you yes or know" -- hell, that program has 10 other people vying for that spot, all of whom would take it in a heartbeat. So you pretty much have to take the offer. Once a program has filled its 2 or 3 spots in November or early December, it doesn't have to interview anyone else, so it's done. So for a highly competitive candidate, you don't have a chance to see more than a few programs before you're almost forced to take one, and then it leaves other qualified and highly competitive people out in the cold because they never got interviewed in the first place. With a match in place, out of match offers can and do occur, but the vast majority of spots are filled in a much more equitable way. Programs can interview many more candidates because they won't be afraid of losing the ones they think they want up front to early offers from other programs, and everyone will have a chance to interview at more programs as a result. Logically, fewer people left out in the cold overall.

4. Obviously, it takes more than just ranking carefully to gurantee a match spot in Cards. I made the statement assuming the candidate had jumped thru all the other hoops like good letters, research, etc. But I can say that in the 3 years I've been keeping up with this stuff, I've never known a single person who has done all of the above not match. I cannot account for poor interview skills or personality deficiencies that come out in the interview either, and those obviously have a huge effect as well.

5. If there were only 60 people applying to Allergy, then your contention would make sense. Start with programs that rank in the top 10-15 in the country. At my own program, we have 4 or 5 applying from my class alone. Now we have a big program, almost 50 categoricals each year, so lets say conservatively that 1 or 2 people apply from each of the other 14 top programs. That's 33 people from the top programs in the country. Now go down the next 15 or twenty programs, say conservatively 1 or 2 each from each one, and you've filled your spots. With only 20-30 programs applying. I'm using the top programs saying that someone from MGH has the name and connections working for them more than someone from UIC. Obviously, that's not always the case, so you keep going down the list. If only one person from each of the university or private medicine programs applies to Allergy this year -- what is that, at least 300 IM programs in the country?, then there are more than 5 people competing for each spot. I'm being very conservative here -- Allergy has gotten very popular, and there are probably more than 1 or 2 people applying each year from the top 50 programs in the country alone. The ratio I've heard from my friends applying this year is 12 applicant for every one spot. It's the same reason that Derm, ENT and Ophtho are so hard to get into, too few spots, too many applicants. If you're gonna argue that the average Cards or GI applicant is smarter than the avg. Allergy applicant, then that's a whole other issue, and I would completely disagree with that assertion.

 

[smackdaddy]

your salary numbers are still off. yes they trail, but so what? everything trails. the salaries for all physicians including cardiologists are very region dependent, but in any case the average difference between noninvasive and invasive is nowhere near 100,000. what's nuclear reimbursement?

i disagree with the effect of the collapse of the gi match on applicants. what i see is that good people are getting good spots early. sure you may quibble if you want to go somewhere it is harder to get into one spot from across the country, but otherwise programs know the quality of applicants they can expect to get. the same people who wouldn't be getting positions anyway are not getting them. the pressure you see is from demand far exceeding supply, not from the collapse of the match. so i think it saves residents who aren't going to get a spot anyway money and time. i think it saves residents who are going to get a spot money and time. the majority of other im fellowships seem to be okay without a match. when you look for a job there is no match.
if you don't know anyone who is a us grad who didn't find a position than that illustrates the challenges in generalizing one's own experiences. sure you can say well this or that but the bottom line is that there are not that many differences between most applicants at the r1 1/2 level. and many do not match for no good reason. your statement is misleading to students who read it, imho.
what is my contention regarding allergy and immunology? i just asked how many good candidates there were. you were the one who said it is the most competitive and that it had only sixty slots. i have no idea how many good applicants there are.
stop projecting your insecurities on me. 😉
going back to anecdotal stories, i do know that everyone i know who wanted allergy found a position without missing a year, and i know dozens of people who didn't find positions in cardiology. although in my experience the ratio of people wanting cardiology versus allergy is about 20:1.
just so there is no misunderstanding, i am not claiming that cardiology is more competitive, i am just asking how many applicants applied to allergy fellowship.

i find it hard to believe there are 12 applicants for every spot.
60*12=720 applicants. i could be wrong though.

 

[task]

Smackdaddy,

I'm actually not going into Allergy, so I have no insecurities to project. But thanks for your concern.🙂

Actually, my salary #s don't trail. Most surveys (which you brought up initially, not me) quote about a $100,000 difference between non-invasive and invasive Cardiologists. Nuclear absolutely reimburses well, but you yourself were quoting averages, so stick to your initial contention. I can always go to rural Arkansas and find an ECHO/non-invasive guy who makes $700,000 a year. But that's certainly not the average. Incidentally, who gives a crap who makes absolutely the most by 50-100k anyway? Why is this such a big deal? Why does this impact why GI is more competitive to get into than Cards or vice versa? As you said yourself, there are always exceptions, and regionall #s will vary.

There are more people who go into Cardiology than Allergy. Big deal. There are more people who go into general Medicine than Cardiology. What's your point?

Actually, you did say in a previous post (about Cardiology) that "it is the most competitive subspecialty in medicine"

No offense, but what you believe is the actual # of candidates applying to Allergy is irrelevant. Like I said in my previous post, I'm only extrapolating based on what's going on in 3 of the top 10 or 15 programs in the country. I think it's fair to say that those 10 or 15 programs have similar demographics in terms of what people go into when you look at all IM programs. I think that's more accurate than "I belive" and "my opinion is".

If you ask any of the candidates who applied to GI this year, whether they matched or not, they will say that the breakdown of the match is the single worst thing that happened to applicants. I asked the GI program director at my own program (which only took people from Parkland for all 3 spots this year). He said, and I quote "the breakdown of the match is to the detriment of the applicants". Here's a much clearer reason than what I explained before. Let's take my own program here. They had hundreds of applications for 3/4 spots (one is given to a research fellow). With GI being rolling, the PDs and selection committee review and offer interviews on a first come, first serve basis. So the first 20 people to get their apps in first are lucky. According to the PD here, if I find 10 people with the #s and the letters to fill my 3 spots among the first 20 applicants, why should I even look at the 21st application. I'll interview the 1st 20 and make my offers, and I'm sure to get 3 takers. Expand this to all the programs offering spots, and you see the problem. In this context, a match confers benefit to applicants because no one has the advantage of getting the application in before someone else. Sure, programs with a match like Cards begin to review apps as they come in, and they offer interviews in a rolling method, but the bottom line is you still get the chance to get interviewed and throw your hat in the ring because everyone faces the same application deadline. You have the chance to go to your interview and impress them with yourself and your credentials in person. In the current environment in GI, the advantage is conferred to those who get their applications in first. At baseline, the majority of these applications are stellar anyway, so take that out of the equation.

The analogy of the job market not having a match is plain silly -- there are not a fixed # of job offers each year. There are plenty of jobs in GI, Cards, etc. that go unfilled. They may not be in the most desirable places, but you can get a job. Hell, you could work at a VA.

Furthermore, you say that the majority of other IM subspecialties are OK without a match (Cards, ID and Pulm have matches). That's because Rheum, Endo, Renal & Heme Onc are not competitive fields to get into. If/when applicant demand for those fields revvs up, watch what happens. That's what happened to GI. When no one wanted to do GI 7 years ago, the match fell apart because programs couldn't fill and they had to scramble to fill spots. Now that there is demand, you the the present situation.

If everyone you know who wants Allergy is getting in, in all seriousness, let me refer people to you/your colleagues who are in for advice, because I know a number of people who would love to match in Allergy.

There are absolutely many people who go unmatched in Cards for no good reason, but there are plenty of people who match who should not have. What you can do to optimize your chances, imho, is to go to the strongest IM program you can, get involved in research and get the right letters. Then interview and rank appropriately. Sure, nothing is a guarantee. But this is the formula I've seen work. I certainly don't know every single person in the country who is applying to Cards fellowship, so with regards to this subject I can only base my contention on the people I've seen match themselves. On the contrary, I think conveying to potential applicants and students a way to get thru the process that has worked for countless others is VERY helpful.

 

[smackdaddy]

i actually didn't have time to read everything you wrote
but it is clear that the demise of the match is detrimental to programs. obviously they interview less and take less time to make decisions. the question is whether they are worse off? i say no, you say yes. the PDs can disagree but the caliber of the applicants is so high IMHO, that the only thing they give up is diversity.
they had all the power and now they don't. their examples support their belief, but so what if they take early applicants? get your application in early. in fact i did talk to several people who matched in gi and they were very happy the match ended. some even used one acceptance to pressure their way into a 'better' program. so again anecdotal stories abound.

as to whether job market is a poor comparison, i don't know what else to compare to. what would you suggest? fellowship positions go unfilled too. the point is they survive without the match, and they seem to be in reasonable shape. what about cardiology? several program operate outside the match. they seem to do okay, and they would potentially have even more pressure and influence over applicants since there are so few of those spots available.

i absolutely agree with you that going to a good program, getting good letters, etc are the best way to prepare for any fellowship application. i disagreed with your contention that any american grad could get in by doing this.

i also don't care who makes more. nice of you to turn it on me, when you were the one who initially started talking about how much people earned and then also brought up payment for procedures. yes i mentioned salaries but only in reply to your initial contention of who made what. and you were the one that pointed out that salary surveys trailed, and now you say they don't. that's okay with me, again i don't really care. or care which is more competitive for that matter.

i did talk to the allergy fellow who said there were 250 applications (give or take ) this year and that this was by far the most applications they had ever received. he also laughed at your salary figures for allergists.

i can't help it if you don't think the number of candidates applying has nothing to do with how competitive a field is. certainly not the absolute number, but the number relative to # of available positions is one indicator of the level of competitiveness. certainly not the complete story, but one marker. if you don't agree, we'll just have to agree to disagree.

in summary, my biggest point in replying to you at all is to re-emphasize my contention that simpy being an american grad and going to a good program and good ranking strategies do not guarantee successful or obtaining of fellowship positions. and that students should be aware that there are no guarantees.
and again i agree with you that those things you outline maximize chances for successfully obtai ning those things.