Does lack of residency prestige place a "glass ceiling" on competitive fellowship program chances?

[toxicadenoma]

Context: Current PGY-1 at a T40ish(?) academic IM residency program who is still debating between pursuing GI or Heme Onc fellowship.

Over the past 4-5 years, our program has been solid at matching residents to competitive fellowships (Cards, GI, etc.) at similarly ranked academic programs, but seemingly struggles when it comes to matching people at what could be considered top programs in competitive locations (think NW, Stanford, UCLA, etc.).

I'm a bit worried about whether or not my institution's lack of name brand places a bit of a "glass ceiling" of sorts on our fellowship match prospects, especially as someone who desires an academic career in very competitive locations. I understand that residency prestige obviously plays some role just like medical prestige did for residency matching, but are my fears warranted? Is there a functional cap on my prospects and should I downplay my expectations going forward? Thanks!

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[dozitgetchahi]

Context: Current PGY-1 at a T40ish(?) academic IM residency program who is still debating between pursuing GI or Heme Onc fellowship.

Over the past 4-5 years, our program has been solid at matching residents to competitive fellowships (Cards, GI, etc.) at similarly ranked academic programs, but seemingly struggles when it comes to matching people at what could be considered top programs in competitive locations (think NW, Stanford, UCLA, etc.).

I'm a bit worried about whether or not my institution's lack of name brand places a bit of a "glass ceiling" of sorts on our fellowship match prospects, especially as someone who desires an academic career in very competitive locations. I understand that residency prestige obviously plays some role just like medical prestige did for residency matching, but are my fears warranted? Is there a functional cap on my prospects and should I downplay my expectations going forward? Thanks!

Maybe, quite possibly, maybe not - it also depends a lot on how competitive the individual candidate is.

My question is why anyone would want to pursue academia in general - especially when one wants an academic job “in highly desirable (read VHCOL) locations. Academic jobs already compensate horribly compared to the rest of medicine, and they pay even worse in the “highly competitive” VHCOL locations where you will need a ****load of money to do basic things (like buying a simple, no frills house). Unless you have a rich spouse or you’re set to inherit a ton of money from someone, you’ll be setting yourself up for a lifetime of financial frustration (been there, done that, bailed to PP where I now make 3X what I was making before, and teach as well…)

 

[NewYorkDoctors]

some have aspirations of doing clinical trials. that's a noble aspiration.

 

[Mehena]

Are you restricted to those locations due to family reasons? There's no such limitation, and most internal medicine residents punch above their weight class and succeed. As you progress in your medical training, prioritize programs with high caseloads and specialized expertise or mentorship over US rankings.
While I'm not in GI, consider Mount Sinai for IBD and perhaps Indiana for advanced endoscopy. In oncology, Boston University offers amyloidosis training, with opportunities to launch your academic career at MSK or MD Anderson. Cleveland Clinic or Indiana are renowned for testicular cancer, and Mayo Clinic for myeloma. These locations may not be in LA or ?Chicago, but they can still lead to positions in academia or private practice post-fellowship in "competitive areas".

 

[dozitgetchahi]

some have aspirations of doing clinical trials. that's a noble aspiration.

Can do that (albeit with a bit more effort) as a PP doc too. Happens fairly frequently in rheumatology. (And I don’t mean just “participating in” clinical trials, but being one of the trial designers. Very easy to participate in trials in PP.)

 

[InternistDO]

Context: Current PGY-1 at a T40ish(?) academic IM residency program who is still debating between pursuing GI or Heme Onc fellowship.

Over the past 4-5 years, our program has been solid at matching residents to competitive fellowships (Cards, GI, etc.) at similarly ranked academic programs, but seemingly struggles when it comes to matching people at what could be considered top programs in competitive locations (think NW, Stanford, UCLA, etc.).

I'm a bit worried about whether or not my institution's lack of name brand places a bit of a "glass ceiling" of sorts on our fellowship match prospects, especially as someone who desires an academic career in very competitive locations. I understand that residency prestige obviously plays some role just like medical prestige did for residency matching, but are my fears warranted? Is there a functional cap on my prospects and should I downplay my expectations going forward? Thanks!

Realistically yes, it does. It's not a complete block, but there's a lot of inbreeding between the top 10-20 IM programs and their fellowship spots and often people outside that can struggle to break in. I remember an APD for a top Ivy League IM program saying that their residents struggled to stay in house sometimes because the spots went to residents from MORE prestigious programs, which is just ridiculous.

How much that actually matters for your life depends on why you want those spots. Do you want an academic career in the sense that you want to run a lab and do research, or academics in the sense that you want to teach and see complex patients? If it's the first then you need to focus on being potentially geographically flexible since you need to prioritize very academic fellowship spots that will give you research time and support.

If it's the second you'll probably realize that even prestige obsessed spots like UCLA or Columbia will hire clinical faculty from less prestigious spots, and you'll also realize that the training at the top 50 to 100 programs is broadly equivalent and unlikely to make a difference in your practice.

 

[whoknows2012]

Maybe, quite possibly, maybe not - it also depends a lot on how competitive the individual candidate is.

My question is why anyone would want to pursue academia in general - especially when one wants an academic job “in highly desirable (read VHCOL) locations. Academic jobs already compensate horribly compared to the rest of medicine, and they pay even worse in the “highly competitive” VHCOL locations where you will need a ****load of money to do basic things (like buying a simple, no frills house). Unless you have a rich spouse or you’re set to inherit a ton of money from someone, you’ll be setting yourself up for a lifetime of financial frustration (been there, done that, bailed to PP where I now make 3X what I was making before, and teach as well…)

Idk maybe bc you spend 15 years in school and training and certain pursuits can only be done in an academic setting. If you invest the time money and opportunity cost in yourself and you want to be the guy/gal treating a very rare subtype of interstitial lung disease or germ cell tumors or insert rare disease x this is likely only to be achievable in an academic setting. Also true if you want to be a physician scientist or clinician investigator.

Money is great, but it’s not the full picture

 

[dozitgetchahi]

Idk maybe bc you spend 15 years in school and training and certain pursuits can only be done in an academic setting. If you invest the time money and opportunity cost in yourself and you want to be the guy/gal treating a very rare subtype of interstitial lung disease or germ cell tumors or insert rare disease x this is likely only to be achievable in an academic setting. Also true if you want to be a physician scientist or clinician investigator.

Money is great, but it’s not the full picture

I’ve discussed my feelings on academic medicine at length here on SDN. If all that floats your boat and you don’t mind the low pay, knock yourself out. But just know that you aren’t being compensated fairly for the value you bring to the table.

I think a lot of docs in academia (particularly fakedemic “clinician educators”) are getting flatly ripped off. And I think a lot of them would be happier elsewhere in medicine (whether their egos let them realize this or not is another thing altogether). Doing high level research is cool, and I can see the appeal there, but working at a large medical center seeing PP volumes for a 50% pay cut just does not make any sense to me.

 

[whoknows2012]

I’ve discussed my feelings on academic medicine at length here on SDN. If all that floats your boat and you don’t mind the low pay, knock yourself out. But just know that you aren’t being compensated fairly for the value you bring to the table.

I think a lot of docs in academia (particularly fakedemic “clinician educators”) are getting flatly ripped off. And I think a lot of them would be happier elsewhere in medicine (whether their egos let them realize this or not is another thing altogether).

i basically agree with the piece about clinician educators. I would say from my experience academicians these days are well aware of the haircut they get on compensation but that’s just my 2cents. Lots of colleagues of mine have left academics for industry the last 2 yrs and less commonly have moved laterally for higher pay.

 

[bronx43]

I’ve discussed my feelings on academic medicine at length here on SDN. If all that floats your boat and you don’t mind the low pay, knock yourself out. But just know that you aren’t being compensated fairly for the value you bring to the table.

I think a lot of docs in academia (particularly fakedemic “clinician educators”) are getting flatly ripped off. And I think a lot of them would be happier elsewhere in medicine (whether their egos let them realize this or not is another thing altogether). Doing high level research is cool, and I can see the appeal there, but working at a large medical center seeing PP volumes for a 50% pay cut just does not make any sense to me.

Totally agree.

Doing high level research sounds cool but it’s largely inaccessible for vast majority of people. If you’re not already plugged into meaningful research under the wings of a powerhouse mentor by residency, it’s already over.

Academics for the masses ends up fakedemia - clinical grunt work for research pay.

 

[toxicadenoma]

Maybe, quite possibly, maybe not - it also depends a lot on how competitive the individual candidate is.

My question is why anyone would want to pursue academia in general - especially when one wants an academic job “in highly desirable (read VHCOL) locations. Academic jobs already compensate horribly compared to the rest of medicine, and they pay even worse in the “highly competitive” VHCOL locations where you will need a ****load of money to do basic things (like buying a simple, no frills house). Unless you have a rich spouse or you’re set to inherit a ton of money from someone, you’ll be setting yourself up for a lifetime of financial frustration (been there, done that, bailed to PP where I now make 3X what I was making before, and teach as well…)

Re. compensation: My spouse is also a resident in a highly-compensated specialty. Our financial prospects would definitely be significantly better if I chose PP or a non-academic career, but we are both happy with living a less extravagant lifestyle in a VHCOL near family while still clearing a significant amount of money per year even if I were to pursue academia.

I think my primary goal is to maintain maximum flexibility regarding options for both academic and potentially private practice options. I’m less concerned about the latter when it comes to fellowship prestige, but I have been told it could come into play given many PPs never publicly post their openings and some oftentimes mainly hire from within an established network from 1-2 institutions in the area.

With the former: I’m under no illusion I will ever be competitive for a place like DCFI or MSKCC given the circumstances, but I do like the prospects of at least having a shot at a big name, well-funded institution with enormous research funding for clinical trials or starting a lab if I chose to integrate research heavily in my future career. My spouse and I would like to settle down in a VHCOL area due to family reasons, so the main academic institutions in the area are primarily the traditional heavy-hitters.

 

[toxicadenoma]

Are you restricted to those locations due to family reasons? There's no such limitation, and most internal medicine residents punch above their weight class and succeed. As you progress in your medical training, prioritize programs with high caseloads and specialized expertise or mentorship over US rankings.
While I'm not in GI, consider Mount Sinai for IBD and perhaps Indiana for advanced endoscopy. In oncology, Boston University offers amyloidosis training, with opportunities to launch your academic career at MSK or MD Anderson. Cleveland Clinic or Indiana are renowned for testicular cancer, and Mayo Clinic for myeloma. These locations may not be in LA or ?Chicago, but they can still lead to positions in academia or private practice post-fellowship in "competitive areas".

Not restricted per se, but my spouse and I would both heavily prefer to establish our practices and settle down in a VHCOL area for family reasons, yes.

 

[dozitgetchahi]

Totally agree.

Doing high level research sounds cool but it’s largely inaccessible for vast majority of people. If you’re not already plugged into meaningful research under the wings of a powerhouse mentor by residency, it’s already over.

Academics for the masses ends up fakedemia - clinical grunt work for research pay.

Totally agree. And even the people who end up “plugged in with meaningful research” often realize it’s not what they wanted it to be:

- Even “well known” researchers often have to publish at least some garbage to keep the grants gravy train running on time.

- Living an entire life that revolves around grant proposals and kissing rich people’s asses for cash at fundraisers frankly sucks.

- Most researchers won’t ever publish anything that is actually game changing…instead you will keep pumping out questionable articles to try to move up in the department etc

Etc etc.

 

[cards67]

Varies by subspecialty. GI is the hardest to climb up a tier while hem-onc is more doable. DFCI and MSKCC can be more competitive due to location while someplace like MDA takes a broader range. But really it's more about research output and extracurriculars. Residency prestige matters to a degree, but an impressive candidate is going to get looks no matter where they come from. This goes for fellowship and jobs. Nevertheless, there's not much you can do about it other than build your resume, apply broadly and see what happens. The fact is that 2 specialized doctors in a desirable HCOL area will have a difficult time finding their dream jobs at the same time, if at all.

 

[shouldigomd]

The simple answer is yes, lack of prestige can place ceilings for some programs but the real answer is that each program is different. Geography, individual department cultures, importance of "diversity," contacts, historical trends and other factors can also play a role of varying degrees.

 

[ShuperNewbie]

For Heme/Onc, the answer to your original question OP is no; if you're from a recognizable academic institution then you shouldn't have an insurmountable glass ceiling in moving up a prestige tier. I can't speak to GI or cards. That said, I don't think prestige is ultimately that important. Prestige is not as big a deal when you start looking for jobs as finding a good mentor and having someone advocate for you.

Just keep your ultimate goal in mind. If you want to settle in a major metropolitan area, just do fellowship as close to that area as you can. It shouldn't be a secret that local grads have an advantage when it comes to local jobs, simply because of the connections that your program will have in that area. It's no accident that a lot of MD Anderson and MSKCC tend to stay local for their first job. If you want to do academics, this principle holds even more true (try to do fellowship as close to your target destination as possible).

People step into different careers for any number of reasons. Yes academics tends to pay less, but as a return they SHOULD protect your time more (this isn't always the case so if you see an academic program that doesn't protect your time, just turn the other way and run) and you get to do cool things on a bigger stage. Someone once told me that there's a triangle of desire in any career in medicine: money, influence, and free time. You can choose two. If you want money and free time, you go into private. If you want influence and money, you go into pharma. If you want influence and free time, you go into academics. There are plusses and minuses to every career path you can walk that'll get more refined the more you go through training. You just have to figure out how those costs and benefits weigh out for yourself.

Also for what it's worth, I've lived in high cost or very high cost or very very high cost of living places nearly my whole life and I've never really struggled that much, even as a resident. That said I'm a very low maintenance dude and don't really covet too many things or try to compare myself to other people, so take that for what it's worth.

I guess what I'm ultimately trying to get at with this whole rambling post is that I don't think any level of prestige is off limits to you (at least in heme/onc), but at least in this field, prestige is much less important than something as simple as training close to where you want to settle down. Good luck OP.