Does it matter where you do your residency?

[tsbqb]

Hey everyone I was hoping to get some insight to a question I have been thinking about.

For current applicants like me, we all spend a lot of time asking which programs give good training and which programs give bad training, which programs have a lot of trauma, which programs have a lot of complicated patients, which programs give a lot of exposure to procedures etc etc

Ultimately, it seems to be, having worked with attendings on my rotations that trained all over that every attending seems competent and capable at the end of their training.

The fact is, ACGME has requirements that every program must fulfill. So as a result of that, every program has to ensure their residents get a certain level of exposure to all areas which have been deemed to be necessary to ensure proper training.

So for all the stress and deliberation on the part of applicants that goes into selecting a residency (or rather making one's rank order list), does every residency graduate come out the same? Or are there some programs that really do offer superior training? Or is residency a situation where "its what you make of it" so that even if you're at a less than stellar program you can make up for that through determination and effort?

I am asking because right now there is a program in a very small town I like. However, there is very little trauma and they have a relatively healthy population and I am just really afraid I wont see all the things I would see in a big urban hospital.

Thanks in advance!

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[deleted109597]

To the degree that you will be competent in a community ED, not really. If a program gets repeated dings from the RRC for subpar training it might not be a place to go, but most aren't like that.
If you've got a specific thing you want to do/study (EMS/US/CCM/International/Admin/Advocacy/Peds), it can make a huge difference. Similarly, if you train at ivory tower, then go to the sticks, you'll be undertrained for the environment you'll get into. So there's always that.

 

[red10]

I think every program I've been to says "our graduates go wherever they want. we have people all over the country in academics and community and fellowships." But it seems to me that its the same as picking a medical school. Will some big names open doors for you easier than that smaller, less well known outside the region school? yea. Will you be incompetent if you don't go to BigNameResearchUniversity? of course not

If you wanna be faculty right out of residency at some big academic center it will probably pay off to have a big name behind you that sends a lot of people on that track.
If you want to ultimately work at Knife&GunClub County Hospital, I'd pick a high flow trauma program.
I feel like everything in between can be achieved from just about any other program with the right amount of effort.

But what to I know, I'm still sorting through it all too

 

[tsbqb]

If you wanna be faculty right out of residency at some big academic center it will probably pay off to have a big name behind you that sends a lot of people on that track.

Thanks but I am asking less about job opportunities post residency and more about clinical skills

 

[red10]

Thanks but I am asking less about job opportunities post residency and more about clinical skills

I think you come out competent wherever. Any program is going to prepare you well to diagnose and treat chest pain, pneumonia and the common cold. Your clinical skills are probably more related to your own effort. Your procedural skills will probably be more related to what you're exposed to frequently and thus your comfort level.

 

[spelledout]

Thanks but I am asking less about job opportunities post residency and more about clinical skills

depends on what you mean by clinical skills... the RRC mandates a certain number of procedures be done in order to graduate - so by all accounts you will be at the minimum required (most likely well above, i'm an intern and i'm already losing track of the number of procedures i've done) as far as that goes.

the other part of clinical skills is how you think about problems. and part of that is up to you, part of that is the patients you see over four years, part of that is how good the faculty are at imparting their wisdom and experience upon you in a way that guides you but doesn't just hand it to you on a silver platter. you can go to the world's most academic institute and not learn a damn thing because no one will teach you. you can also go to the community hospital in the middle of nowhere and not learn a damn thing.

and unfortunately, where graduates get jobs is the best indicator for the clinical experience you get, as a generalization (there are always bad residents in good programs and good residents in less than good programs). Jobs want to fill their positions with doctors with good clinical skills. And you'll find that they keep going back to the same well time and again, because it's a trusted source.

 

[emergentmd]

I don't think it really matters much if you want a community hospital job. I contend that its more about your personality than really how bright you are.

I would always recommend working in a county/level 1 hospital b/c you may never see similar stuff in the community. I trained at a level 1/Trauma center and I took care of alot of sick pts and was never hand held. I made alot of mistakes but I learned alot from it. I feel working in a community hospital after residency was an easy transition

 

[Birdstrike]

Most of Emergency Medicine is "self referral." What walks (or rolls) in, is what walks (or rolls) in. You could make the argument, that if what you want to be is just an excellent ER doctor, that the more "ordinary" the place is at which you train, the better skills you'll have. If what you get see most is "transferred from St Nowhere, admit to Medicine for liver transplant" then that's what you're going to be best at. Or, if what you get good at, is being one of 21 people in a room during a trauma, then that is what you'll be good at.

Some would say, you'll learn more, or have your skills tested more, by being a single doc and nurse in a community ED with traumas dropped at your back door, out of said El Camino.

I suppose balance is best, and also hardest to find.

 

[danielmd06]

Some would say, you'll learn more, or have your skills tested more, by being a single doc and nurse in a community ED with traumas dropped at your back door, out of said El Camino.

I suppose balance is best, and also hardest to find.

You deserve props for managing to work an El Camino into the conversation.

 

[Birdstrike]

You deserve props for managing to work an El Camino into the conversation.

Lol

#Wordsmith

 

[tsbqb]

I suppose balance is best, and also hardest to find.

Right and thats my point. We can perhaps agree on paper what would make a perfect residency. However every program has their strengths and weaknesses and applicants are told all kinds of things. So with that in mind, does program A = Program B = Program C in terms of turning out proficient physicians?

I guess another way of putting it is: are there programs that are known for producing attendings who aren't very good? (you dont need to name the program if you dont want to)

Or also, are there any attendings out there who graduated residency and felt less capable compared to their peers of equal experience?

Thanks for all the replies so far!

 

[goodoldalky]

You will get adequate training at any accredited residency. There are some places, however, where you will get outstanding training that exceeds the minimum standards. You can go to a program where all the residents get their 50 intubations and 50 lines, or you can go to a program where you will get 150 tubes and lines. You can go somewhere where you are not terribly busy and always supervised to the nth degree or you can go somewhere very busy where you end up being forced to do a lot of things independently. The latter is better for your training and generally speaking for obtaining competitive community or certain academic jobs, particularly regionally. You can get a job no matter what residency program you go to but not all programs provide equal training.

To speak to your last question, the quality of prior graduates from your program will impact employers' assumptions about your level of training.

 

[Apollyon]

To speak to your last question, the quality of prior graduates from your program will impact employers' assumptions about your level of training.

What that means, though, is, if the last person through became an all-star at the job, they think good things. If you then come in on that rep, and you turn out to be a turd, they'll be wary. One more dud, and your program is no longer a "feeder", irrespective of the overall quality of everyone else there.

My program was weak when I was there (is much more robust now, 7 years after I'm gone - like the balloons for the Macy's parade before they're inflated and after), but the institutional name worked for me to get my first job.

Tip O'Neill said "all politics is local", and so is EM. Even if you see for "miles and miles", EM is only what you can touch. People only know their local area (generally); think of resistance patterns. Likewise, people don't come from states away to come to your ED. They might come to your hospital and come through the ED to get to the world class whatever upstairs, but they did NOT, and do NOT, come there for you.

So, if the employers get extraordinary lucky, each person from a certain program can be amazing, while a parallel employer gets the leavings, and job #1 says that "In and Out EM" is an extraordinary program, and job #2 says that "In and Out" IS #2 for EM. And, for the most part, job #1 and job #2 don't know just about anything about each other, in real time (only historical, from people that change jobs).

 

[JediZero]

You will get adequate training at any accredited residency. There are some places, however, where you will get outstanding training that exceeds the minimum standards. You can go to a program where all the residents get their 50 intubations and 50 lines, or you can go to a program where you will get 150 tubes and lines. You can go somewhere where you are not terribly busy and always supervised to the nth degree or you can go somewhere very busy where you end up being forced to do a lot of things independently. The latter is better for your training and generally speaking for obtaining competitive community or certain academic jobs, particularly regionally. You can get a job no matter what residency program you go to but not all programs provide equal training.

To speak to your last question, the quality of prior graduates from your program will impact employers' assumptions about your level of training.

I have a question that might totally hijack this thread, and for that I apologize, but: Does this apply to AOA programs as well? There are some programs in very rural locations (coughcoughOhiocough) that are training 2-3 residents per year, spreading across three hospitals that see 30k patients a year. To me, that alone sounds suspect. To those who have worked with DO attendings from BFE residencies, have you noticed a difference in their competency/training?

 

[DeadCactus]

Any residency will train adequately for whatever job you start next. The individual is far more of an issue than the program. After that, you'll get good at what you practice and the other skills will atrophy.

Far more of an issue than the training is the networking. If you want to do academics, it's going to be a clear advantage to have the chance to work regularly with the big names in EM. If you want to live in a specific area, it's going to be a clear advantage to train in that area.

 

[alpinism]

Very rural + 30k pt volume as a resident = no thanks.

You may get "adequate training" at any residency, but why settle for just adequate?

On the other hand, if you only want to practice community EM in rural Ohio, it might be the perfect fit.

 

[gman33]

As long as you see enough patients and study on your own, pretty much any place will train you.
You need to have some insight into your own learning style and career goals to figure out what program will be best for you.
An academic career is a little different, the CV is much more important.

Some programs will spoon feed your learning, may be good if you need or want that.
Other places, you will mainly see patients with less teaching on shift.
That may be good or it may not be.
At some point you need to learn to make your own decisions.
The programs with less teaching, may make this happen.

Also, don't base your decision on patient volume.
Acuity is more important. Staffing is generally geared towards volume.
I couldn't see any more patients if I wanted to, so if the volume was double it wouldn't make any difference.
Maybe you could see a few more rare things. I don't know if I believe this anyway.
Another program in my same city has 50% more volume than our main shop.
They have twice as many residents on shift, so that doesn't mean more learning opportunities.

 

[tsbqb]

You may get "adequate training" at any residency, but why settle for just adequate?

Well ideally you never would settle for that. However, there is a program I am very interested in that I dont think offers the best training clinically, but I love the people there, and its in a location I want to be etc.

I am sure a lot of people find themselves in similar situations.

 

[gman33]

One person's "adequate" training, might be great for someone else.
One program I liked was very teaching focused.
A lot of teaching during shifts and didactics every day.
Given a limited amount of time, this program would have you see significantly less patients than some others.

If you don't need or want this amount of teaching, it might be a horrible program for you.
For others, it might be amazing.

With the proliferation of podcasts, online lectures etc, you can get world class didactics anywhere you go.

A lot of things I thought were important, just seem annoying now.

Go where you think you will be happy for 3-4 years.
You can work the rest of it out.
This is especially important if you have a significant other involved.

 

[namethatsmell]

Well ideally you never would settle for that. However, there is a program I am very interested in that I dont think offers the best training clinically, but I love the people there, and its in a location I want to be etc.

I am sure a lot of people find themselves in similar situations.

If you think you've found the place where you will be happiest then you've found your #1. Nobodys want to go a place where the clinical training "isn't the best" but the whole idea of what the "best" clinical training is going to be highly subjective and different to everybody. Chances are good that the training at the program you're referring to is solid and the happier you are in residency the better you will do. And I agree with others that "how good you will be" when you're done with residency largely rests on you.

FWIW, my 2 cents on what to look for in a residency (beyond "gut feeling"):

Important...
-a place which exposes you to different hospitals with distinct patient populations--ideally county/level 1, community, and tertiary
-diverse faculty--so you'll appreciate different ways to manage patients (ie not just "the way" your program does chest pain)
-varying types of acuity--seeing lots of "sick" patients is good...but seeing a mix of sickies from all walks of life like septic players, 20 untreated chronic disease players, esrd players, onc players, transplant players, etc is better
-you can see the sickest patients from day one and get to do the relevant procedures
-strong peds

Somewhat important...
-a place that sends its grads all over the country
-a place with specific niche areas of interest to you (ie strong EMS, policy wonks, or whatever)

 

[namethatsmell]

Oops well it looks like I just posted the same sentiments as the guy above me. That's what I get for writing this post 2 hours ago but forgetting to post due to football.

 

[herewego]

this is a great topic, and something I'm struggling with as an applicant this cycle. Theres some great institutions out there that train monsters, and have strong reputations that can land you a job anywhere in the country, but the location isn't that great or I don't gel with the residents vs less prestigious programs, maybe their training isnt as strong comparatively, but love the location and gel with the residents.

I want to be happy for the next 3-4 no doubt about it, but it really seems like the more prestigious institutions set you up well for the rest of your life, assuming same amount of hardwork. Definitely seems like the grads of the big institutions get the jobs.

Does anyoen feel else feel like not going to a more prestigious place might be hurting your long term career? I don't know if I want to stay in academics, but I don't want to shut any doors early on either. Thoughts?

 

[kkinase]

I'm also in a bind with strong programs with national reputations and the local decent EM program that just seems better to be at. In the end, I lean more on having all door open and being able to go anywhere in the country so I most likely will rank the reputable ones above the others. Plus I want to fast track into academics anyway so makes more sense for me.

 

[EMdoc10]

Yet all the community progs say your experience will be "as good as you make it", you'll get "as much as you put in", and "we send people everywhere"- both community and academics. I'm w herewego...strugglinggg

 

[joeDO2]

I think I posted this link somewhere a while back... http://www.denverem.org/index.php?option=com_content&view=article&id=14&Itemid=3

It is a great article from denver on what to look for in a residency program outside of the general good fit.

 

[TooMuchResearch]

I think I posted this link somewhere a while back... http://www.denverem.org/index.php?option=com_content&view=article&id=14&Itemid=3

It is a great article from denver on what to look for in a residency program outside of the general good fit.

Yeah, it's pretty good. Just remember that whoever authored it is selling a program.

 

[alpinism]

Well ideally you never would settle for that. However, there is a program I am very interested in that I dont think offers the best training clinically, but I love the people there, and its in a location I want to be etc.

I am sure a lot of people find themselves in similar situations.

Absolutely. I think everyone has a few programs they really like for whatever reason (location, people, near family, etc…) that aren't as strong clinically or don't have the best curriculum that matches their needs.

Re: pt volume, its more a function being exposed to less acuity and less diversity of pathology at community programs with smaller volumes than the actual numbers themselves (30K v. 70K).

 

[MSUSpartan642]

Absolutely. I think everyone has a few programs they really like for whatever reason (location, people, near family, etc…) that aren't as strong clinically or don't have the best curriculum that matches their needs.

Re: pt volume, its more a function being exposed to less acuity and less diversity of pathology at community programs with smaller volumes than the actual numbers themselves (30K v. 70K).

Is there a range of volumes of programs that people would say are best? Like 60-90K? Just wondering.

 

[RPedigo]

Is there a range of volumes of programs that people would say are best? Like 60-90K? Just wondering.

I think it also depends on the number of residents -- for instance, if an ED sees 100,000 patients/year and is staffed by 60 residents (15/yr PGY1-4) that's much different than if an ED sees 90,000 patients/year and is staffed by 30 residents (10/yr PGY1-3). That said, higher volume is never a bad thing.

 

[TooMuchResearch]

I think it also depends on the number of residents -- for instance, if an ED sees 100,000 patients/year and is staffed by 60 residents (15/yr PGY1-4) that's much different than if an ED sees 90,000 patients/year and is staffed by 30 residents (10/yr PGY1-3). That said, higher volume is never a bad thing.

And you still won't have a clear picture unless you also know how many PAs work in the ED, if they have sections run by attending/PA only, if they see pts in a separate triage area and treat the easy ones there during peak flow, etc.

Edit: There are some who would argue that beyond a certain number, higher volume becomes a bad thing.

 

[bougiecric]

My impression is that reputation of an institution matters if you plan on going into academics. And despite whatever intentions you have now, the vast vast majority of residents end up in the community. What matters most in the community? "Board certified in emergency medicine." (At least where I work) there's still a large number of EDs staffed by FM/IM. Many places fight left and right over BCEM physicians.

I hate to break it to you, and this admittedly depresses me, but nobody cares how good you are at emergency medicine. Seriously, they don't at all. You get no recognition, no kudos for being a good doc. Nobody pats you on the back for getting near perfect alignment of that distal radius fracture. Nobody cares that you expertly managed the acute pulmonary edema, saving them from being tubed. Nobody is impressed that you picked up the free fluid from a ruptured ectopic on bedside ultrasound. As long as people aren't obviously being harmed (and you don't miss your core measures!), nobody cares how you practice medicine.

What do employers look for in a doc? RVUs generated. Yep, that's it. Make money. The first question I was asked by prospective employers: did your residency calculate RVUs/hr? Where did you stand? How about patients per hour? RVUs. RVUs. RVUs. Patients. Patients. Patients. Door to greet! Length of stay! Bah.

So let's say that you actually care how good you practice medicine. That you want to be the best doc possible. Again, you're doing this for yourself and for your patients, because you truly care. I do care, as many of us do. But understand that there are a significant number of docs out there who really don't, and they get along just fine. So what residency to go to, if you want to be a skilled emergency physician?

I'm not convinced that absolute higher volume is better. Your residency could see 100k a year, but if you're poking along at 1 pt/hr your third year, well, all those patients aren't really helping your education. It's also my experience that at these higher volume places, the more consultarrhea that takes place. Fracture/dislocation? Call ortho, ask to help. 3rd degree AV block? Call cards, send them to the lab. Pediatric intubation? 8 peds anesthesiologists lined up at the bedside. As well, at one "unnamed" institution, midlevels and residents picked up patients equally. Patient with a PTX that the PA picked up? Tough luck resident, PA does the chest tube. And be careful, because no way are places going to advertise that this goes on.

One of my coworkers finished residency ~4 years ago. She came out of one of the "100k visits/year urban battle ground I cracked 3 chests today" residencies. She is incredibly slow. The department backs up and the nurses groan when she's on. She admits anyone with a sugar over 200. The only lines she places are blind fem lines "because I'm scared of hitting something up above." She had no clue that ACEP/AAN recently released a controversial stroke clinical policy. She doesn't keep up and doesn't really care to. Bedside ultrasound? Hahahahaha.

My point is that you can be a crappy doctor no matter where you train. EM is unique in that our field doesn't need to be in a tertiary care center to see good cases. You may not be able to learn liver transplantation in a community hospital, but you sure as hell will see an ACEI induced angioedema. Patients don't discriminate where they get their emergency care.

So yeah. The only piece of advise I have: work your ass off, wherever you go, and you will become a good doctor. Stay a little late to see that interesting case. Try to see as many patients as possible, safely. Keep up on the literature, read your textbooks, follow FOAM online. Always, always dive headfirst into discomfort (with supervision, of course).

Go where you like. If you wanna work in the community, it shouldn't be a problem... until the midlevels take over.

 

[tsbqb]

My impression is that reputation of an institution matters if you plan on going into academics. And despite whatever intentions you have now, the vast vast majority of residents end up in the community. What matters most in the community? "Board certified in emergency medicine." (At least where I work) there's still a large number of EDs staffed by FM/IM. Many places fight left and right over BCEM physicians.

I hate to break it to you, and this admittedly depresses me, but nobody cares how good you are at emergency medicine. Seriously, they don't at all. You get no recognition, no kudos for being a good doc. Nobody pats you on the back for getting near perfect alignment of that distal radius fracture. Nobody cares that you expertly managed the acute pulmonary edema, saving them from being tubed. Nobody is impressed that you picked up the free fluid from a ruptured ectopic on bedside ultrasound. As long as people aren't obviously being harmed (and you don't miss your core measures!), nobody cares how you practice medicine.

What do employers look for in a doc? RVUs generated. Yep, that's it. Make money. The first question I was asked by prospective employers: did your residency calculate RVUs/hr? Where did you stand? How about patients per hour? RVUs. RVUs. RVUs. Patients. Patients. Patients. Door to greet! Length of stay! Bah.

So let's say that you actually care how good you practice medicine. That you want to be the best doc possible. Again, you're doing this for yourself and for your patients, because you truly care. I do care, as many of us do. But understand that there are a significant number of docs out there who really don't, and they get along just fine. So what residency to go to, if you want to be a skilled emergency physician?

I'm not convinced that absolute higher volume is better. Your residency could see 100k a year, but if you're poking along at 1 pt/hr your third year, well, all those patients aren't really helping your education. It's also my experience that at these higher volume places, the more consultarrhea that takes place. Fracture/dislocation? Call ortho, ask to help. 3rd degree AV block? Call cards, send them to the lab. Pediatric intubation? 8 peds anesthesiologists lined up at the bedside. As well, at one "unnamed" institution, midlevels and residents picked up patients equally. Patient with a PTX that the PA picked up? Tough luck resident, PA does the chest tube. And be careful, because no way are places going to advertise that this goes on.

One of my coworkers finished residency ~4 years ago. She came out of one of the "100k visits/year urban battle ground I cracked 3 chests today" residencies. She is incredibly slow. The department backs up and the nurses groan when she's on. She admits anyone with a sugar over 200. The only lines she places are blind fem lines "because I'm scared of hitting something up above." She had no clue that ACEP/AAN recently released a controversial stroke clinical policy. She doesn't keep up and doesn't really care to. Bedside ultrasound? Hahahahaha.

My point is that you can be a crappy doctor no matter where you train. EM is unique in that our field doesn't need to be in a tertiary care center to see good cases. You may not be able to learn liver transplantation in a community hospital, but you sure as hell will see an ACEI induced angioedema. Patients don't discriminate where they get their emergency care.

So yeah. The only piece of advise I have: work your ass off, wherever you go, and you will become a good doctor. Stay a little late to see that interesting case. Try to see as many patients as possible, safely. Keep up on the literature, read your textbooks, follow FOAM online. Always, always dive headfirst into discomfort (with supervision, of course).

Go where you like. If you wanna work in the community, it shouldn't be a problem... until the midlevels take over.

Awesome post. Very sad but awesome. Thank you

 

[fiznat]

As well, at one "unnamed" institution, midlevels and residents picked up patients equally. Patient with a PTX that the PA picked up? Tough luck resident, PA does the chest tube. And be careful, because no way are places going to advertise that this goes on.

Why is this program unnamed? ...Or have I just been absent from this forum enough recently to miss the reference?

I would think places with a policy like that ought to be well known in a community like this!

 

[tsbqb]

What do employers look for in a doc? RVUs generated. Yep, that's it. Make money. The first question I was asked by prospective employers: did your residency calculate RVUs/hr? Where did you stand? How about patients per hour? RVUs. RVUs. RVUs. Patients. Patients. Patients. Door to greet! Length of stay! Bah.

Is this true in academics as well?

Is there really no regard for actually being an excellent EM doctor? Bad doctor=good doctor once residency is over?

 

[TooMuchResearch]

Is this true in academics as well?

Is there really no regard for actually being an excellent EM doctor? Bad doctor=good doctor once residency is over?

My understanding is that in the community, RVUs and metrics are run the show. I am still going to attempt to be the best EM doc I can be because I think it will benefit the occasional patient.

Edit: Hey...where did my profile pic go? It has been missing since the site update, right?

 

[gman33]

There are many aspects to being a "good doctor." If you are not efficient and the department blows up every time you work, you will be hated be your collegues.
Some more "academic" docs are amazing with an individual patient, but terrible at running the department.