DO Stigma in residency/fellowship

[Dr.Bruh]

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My school had an EM panel of 4th year who matched EM last year. I asked if any of them (5 total) felt unprepared or behind compared to MD student while they did away rotations at academic program. All of them said no not at all and one said he felt like they knew less. Still anecdotal but they all car from my DO which has no home hospital or EM program and none of our EM rotations are with residents (that I’m aware of).

 

[Chibucks15]

My school had an EM panel of 4th year who matched EM last year. I asked if any of them (5 total) felt unprepared or behind compared to MD student while they did away rotations at academic program. All of them said no not at all and one said he felt like they knew less. Still anecdotal but they all car from my DO which has no home hospital or EM program and none of our EM rotations are with residents (that I’m aware of).

This is the key. I think the overarching sentiment on here overestimates how truly prepared most MDs are. Sure, there are rockstars in both sides which are more individual based than rotation based. I’ve rotated with MDs doing aways and didn’t notice a difference from DOs (from established schools...the students from new ones I’ve seen can be rough)

 

[Hippocrates II]

Can someone explain to me why working within a team of residents/attendings/students is so much more preferred over the 1:1 preceptor-based learning, or is this just another talking point repeated ad nauseam on here that doesn't have much depth? There are so many posts on SDN about people having great preceptors that teach them a ton, and then they're immediately dumped on because it wasn't taught within some grand medical team. The only real downside I can imagine with a preceptor-based rotation is that you might have a bad preceptor, but even people saying that they had a great one is still be ridiculed on here.

I understand you need some exposure to working within a medical team so that you're prepared for residency. To my naive mind, though, it seems like learning how to function within a team is not going to require 2 years to figure out, but the education you might (I realize this is preceptor-dependent, and thus sinks or swims a rotation) receive on a 1:1 rotation sounds a lot more valuable and difficult to learn rather than figuring out your lowly place in line within a medical team.

I used to see some of the MD medical students rotate at a site affiliated with my local university and most of them were just sitting there passively listening to an attending primarily teach residents. Did not strike me as this high and mighty educational tool that is so highly lauded on here. Granted I've never been on a rotation, so I'm curious to hear what the rationale behind this is.

 

[Sardonix]

Can someone explain to me why working within a team of residents/attendings/students is so much more preferred over the 1:1 preceptor-based learning, or is this just another talking point repeated ad nauseam on here that doesn't have much depth? There are so many posts on SDN about people having great preceptors that teach them a ton, and then they're immediately dumped on because it wasn't taught within some grand medical team. The only real downside I can imagine with a preceptor-based rotation is that you might have a bad preceptor, but even people saying that they had a great one is still be ridiculed on here.

I understand you need some exposure to working within a medical team so that you're prepared for residency. To my naive mind, though, it seems like learning how to function within a team is not going to require 2 years to figure out, but the education you might (I realize this is preceptor-dependent, and thus sinks or swims a rotation) receive on a 1:1 rotation sounds a lot more valuable and difficult to learn rather than figuring out your lowly place in line within a medical team.

I used to see some of the MD medical students rotate at a site affiliated with my local university and most of them were just sitting there passively listening to an attending primarily teach residents. Did not strike me as this high and mighty educational tool that is so highly lauded on here. Granted I've never been on a rotation, so I'm curious to hear what the rationale behind this is.

Having done all of 3rd year at a rural 1:1 site and now completed a couple SubIs, you ask a very fair question.

The biggest thing I've found to support the "MDs are way better prepared" is that in formal teaching environments it's simply easier to function as a student. Nurses know who you are, there are support staff to help you access the EMR, you get to work on notes (yay), and most importantly you get lots of help working on your oral presentations.

Physicians in established teach facilities also know what is important to teach. I can definitely tell you as nice and welcoming as my 3rd year attendings were, sometimes they simply did NOT have a practice that could both function under the demands of organization AND effectively teach. Sometimes they simply didn't know what to teach and would just point out random stuff they thought was cool. A lot of times I didn't do many notes and didn't do many in depth patient presentations either.

For very competitive specialties, I can only assume there are many more benefits--there simply isn't enough weird pathology or cool surgeries out in the boonies. They really do need those big academic centers to get better training and develop their confidence.

You are right though--for the most part, once someone gets accepted into a program they will struggle 1st year but they WILL learn all the things they need to learn--note writing, presentations, clinical skills, communication, team structure etc. Sometimes all the hand wringing about DOs being disadvantaged is overblown. It all comes down to what specialty you want to go into and how heavy the expectations are for you to be 110% right out of the gate. For FM or IM? Not that big of a deal. For surgery? You need every advantage possible.

 

[InternistDO]

Having done both types of rotation, I will say this--a good 1:1 preceptor rotation can be really really good (write notes, individualized teaching, chance to do procedures/first assist, etc) but a bad preceptor can mean you learn almost nothing and sit in the corner all day. Conversely, since interns and residents are constantly being taught stuff, it's hard to not learn things on a traditional academic rotation even if it's a less strong one.

Regardless, the assumption that programs have is academic rotations are better so I would prioritize those as much as possible, especially for the purpose of getting letters.

 

[Goro]

Comments like these are so subjective lol. I think we can get a better idea by asking how many D.O interns feel under trained compared to M.D interns (in July)

My OMSIIIs routinely say that they feel well prepared for rotations; their preceptors agree, and the students are also surprised that some MD students form Really Top Schools that they rotate with could rattle off details of, say, acidic ketoacidosis, but couldn't take a patient history to save their lives.

 

[Sardonix]

My OMSIIIs routinely say that they feel well prepared for rotations; their preceptors agree, and the students are also surprised that some MD students form Really Top Schools that they rotate with could rattle off details of, say, acidic ketoacidosis, but couldn't take a patient history to save their lives.

Quote from an MD resident: "I spent so much time memorizing these random-a** diseases for a stupid board score, but then I had to relearn it all in residency except in a useful way this time. What was the point?"

Not saying DOs have a leg up in this case, just that EVERYONE can be equally frustrated with the education process lol.

 

[Angus Avagadro]

Both situations have value. Preceptor based rotations have more hands on stuff for the student. You are right there with the attending for most of the time. Most of our preceptor rotations were rural, so you see a wide variety of pathology. The university teaching model is more academic with lots of bedside teaching, noon conferences, and journal club. This is where you learn to dissect a journal article critically. From a hands on perspective, you are way down the line to do any procedures. Although long ago, I did not feel unprepared for internship. When I worked as a pgy 2, I actually felt better prepared than many of my co residents. Mostly in procedures and having a good generalist backround.

 

[IntheClouds4ever]

meh.. Ive done mostly rural rotations, a few big academic rotations, and a handful of rotations at various residency programs. I am on auditions at the moment. I hated the big academic inpatient rotations.. always at the back and it was boring AF. Ive loved my more rural rotations and they honestly have proven to be immensely useful for auditions for doing procedures and jumping in when appropriate. After doing a handful of intubations, dozens of lac repairs of varying difficulty, central lines, art line, vaginal deliveries, and etc., on the more 1 on 1 rural rotations or working with 3rd year residents who already have their procedure numbers have made auditions a breeze.. In the last week on an audition, Ive done 3 intubations, multiple lac repairs, and central lines without hesitation. Ive been killing it in the ICU with the max patients allowed for auditioners and collaborating with the resident before rounds on their more difficult patients- this is far more engaging and Ive learned more with these types of experiences than any pimping on rounds.

Maybe Im just lucky and have had exceptional preceptors and residents on my smaller/rural rotations, but I wouldn't have changed a thing. I think you have to be aware of what rotations you have chosen if you go smaller so that you get the best bang for your buck. Its BS of "learning to work as a part of a team" as a reason to go for big academic center rotations only.. You learn to work as a team in grade school, not medical school.. If you are just now learning that, you probably have more problems than you realize.

 

[AlteredScale]

My third year rotations were all preceptor based except for 1 IM rotation with an MD residency program with MD students. These students were extremely comfortable with note writing and presenting in a structured format and did it with ease. I struggled with it and it took probably 2 weeks before I could catch on. Now when it came to actually formulating a plan or being asked about diagnosis or what not I did not feel that there was much of a difference.

Come fourth year and doing a subspecialty Sub-I, I am very happy I had the exposure at least once as it let me hit the ground running with the program and could spend more time being as productive as possible (I became the "OSH document retriever" lol)

Every university service has a different expectation of their student, I have 1 colleague where this type of super formal presentation was barely used at his Sub-I at a Southeast Uni program.

 

[hallowmann]

There is a major heal care provider in CA that is opening a new med school in Pasadena in 2020 that recently asked my wife if she wanted to be seen by a DO or an MD. LOL.

They're paying DOs and MDs alike quite a bit to be PCPs. If it weren't for the horror stories I heard from people that work for them, I might even bite.

 

[NurWollen]

There is a major heal care provider in CA that is opening a new med school in Pasadena in 2020 that recently asked my wife if she wanted to be seen by a DO or an MD. LOL.

They're paying DOs and MDs alike quite a bit to be PCPs. If it weren't for the horror stories I heard from people that work for them, I might even bite.

Wait wait this is a thing? Asking patients if they want a DO or MD? I've honestly never heard of this happening until now.

 

[Dreamstoo]

Wait wait this is a thing? Asking patients if they want a DO or MD? I've honestly never heard of this happening until now.

May be anecdotal but a relative of mine whose worked at Kaiser said the anti-DO bias is a thing (personally didn't agree with it but has seen Carib MDs get attending offers quicker than DOs).

 

[Angus Avagadro]

Wait wait this is a thing? Asking patients if they want a DO or MD? I've honestly never heard of this happening until now.

I have had the opposite. Never had an objection by a patient. Actually, had a couple dozen phone calls over the years wanting to see me because I was a DO or asking me for a referral to a DO in their area who focused on OMM, now called NMM, neuromuscular medicine. It would not bother me in the least if someone wanted one of my former MD colleagues to take care of them. You really dont want a patient who doesnt have full confidence in your abilities. I consider this kind of bias similar to patients demanding to be seen to by our Chairman. In many cases the Chairman was hot stuff 20 yrs ago, but has been behind a desk for years. Other more capable associates might be in the dept, but indulging the patient is the best path IMO.

 

[hallowmann]

I've actually only experienced people asking for DOs to be honest. Saying things like they treat people more holistically or wanting OMM. I'm sure it happens the other way around, but I probably don't meet those people.

 

[Dr.Bruh]

I've actually only experienced people asking for DOs to be honest. Saying things like they treat people more holistically or wanting OMM. I'm sure it happens the other way around, but I probably don't meet those people.

Yeah the general public eats that crap up. We get biased against in academia but in the public they fall for holistic stuff so much.

 

[DrStephenStrange]

Yeah the general public eats that crap up. We get biased against in academia but in the public they fall for holistic stuff so much.

Well, I don't mind if they fall for it lol.

 

[jurassicpark]

Physicians in established teach facilities also know what is important to teach. I can definitely tell you as nice and welcoming as my 3rd year attendings were, sometimes they simply did NOT have a practice that could both function under the demands of organization AND effectively teach. Sometimes they simply didn't know what to teach and would just point out random stuff they thought was cool. A lot of times I didn't do many notes and didn't do many in depth patient presentations either.

This is the crux of the matter. Preceptors oftentimes are not "professional" academics/teachers. They are far removed from the stuff that you're learning as a third year it's hard for them to translate it across what they essentially do as reflex. The stuff you have to know for your boards they've loooong since forgotten (or have consultants for). Preceptorship is a mixed bag since there's also no real unifying standard to keep them accountable for except their own conscience.

For myself, I am in constant communication with the school for feedback and updates on what my students need to be learning, or feel they need to be learning, because god forbid they may have to treat me one day. But one thing I feel every third year medical student needs to learn to do is do a proper SOAP note, and it's utterly satisfying to watch when they start and can only put one thing under their assessment, to rolling out a massive A/P at the end that actually makes sense.

 

[Angus Avagadro]

This is the crux of the matter. Preceptors oftentimes are not "professional" academics/teachers. They are far removed from the stuff that you're learning as a third year it's hard for them to translate it across what they essentially do as reflex. The stuff you have to know for your boards they've loooong since forgotten (or have consultants for). Preceptorship is a mixed bag since there's also no real unifying standard to keep them accountable for except their own conscience.

For myself, I am in constant communication with the school for feedback and updates on what my students need to be learning, or feel they need to be learning, because god forbid they may have to treat me one day. But one thing I feel every third year medical student needs to learn to do is do a proper SOAP note, and it's utterly satisfying to watch when they start and can only put one thing under their assessment, to rolling out a massive A/P at the end that actually makes sense.

I get what you're saying. 3rd yrs need to learn the basics of how hospital and office based practices function. They need to learn the basic with respect to common conditions and therapies, meds, the EMR, etc. Breaking their stones over the nuance of Common Variable Immunodeficiency Syndrome is not in their interest, although board relevant. How Metformin works would be. History of present illness, associated symptoms, assessments and plan should be emphasized. Every third year requires a different approach as some come with stronger backgrounds than others. When preceptors dont recognize this is what makes for a poor experience for the student

 

[jurassicpark]

I get what you're saying. 3rd yrs need to learn the basics of how hospital and office based practices function. They need to learn the basic with respect to common conditions and therapies, meds, the EMR, etc. Breaking their stones over the nuance of Common Variable Immunodeficiency Syndrome is not in their interest, although board relevant. How Metformin works would be. History of present illness, associated symptoms, assessments and plan should be emphasized. Every third year requires a different approach as some come with stronger backgrounds than others. When preceptors dont recognize this is what makes for a poor experience for the student

Exactly. Busting their chops over something exotic is all fun and games to watch them sweat and squirm but they need to learn basics first before they can fly. In the normal course of events, a brand-spanking new third year should be taught by their fourth year or intern/resident who a) has the time and b) much closer to remembering how it was taught and problems they faced. An Attending "in the field," so the speak will have a hard time doing that for a myriad of reasons not to mention lack of time. This is a common complaint we are facing and trying to actively correct. But as stated, preceptors for the most part are doing this out of the kindness of their heart and a genuine interest in helping future doctors, but it's hard to enforce anything.

 

[Angus Avagadro]

Exactly. Busting their chops over something exotic is all fun and games to watch them sweat and squirm but they need to learn basics first before they can fly. In the normal course of events, a brand-spanking new third year should be taught by their fourth year or intern/resident who a) has the time and b) much closer to remembering how it was taught and problems they faced. An Attending "in the field," so the speak will have a hard time doing that for a myriad of reasons not to mention lack of time. This is a common complaint we are facing and trying to actively correct. But as stated, preceptors for the most part are doing this out of the kindness of their heart and a genuine interest in helping future doctors, but it's hard to enforce anything.

Steve Vai, the famous rock guitarist taught a course at Juliard. He showed up with an acoustic guitar and spent an hour playing classical music. When asked by the students when they would learn some rock, he said, " You have to learn the rules before you can break the rules" I believe this holds true in medicine.