Factors to consider for Rank List

[deleted986199]

Hi current residents/attendings/fellows,

I am a fourth year who applied anesthesia.


This residency cycle was unlike no other with virtual interviews. As a result, candidates did not have the opportunity to travel to said institutions, see the surrounding area, and meet residents and faculty in-person. Resident pre-interview dinners were not the same experience.


As a result, I was hoping for any advice you may in regards to ranking programs. I know that determining one’s rank list is unique to one’s individual preferences, values and goals but I would love to hear about what your approach was and any advice you may have to me and other candidates struggling this year.

I understand that gut instinct, location, prestige and a presence of a support system are all important factors. However, with the virtual aspect of this year, it’s been incredibly difficult to rely on gut for rank purposes when our interactions with programs are so limited. It's also easy to hide behind a screen.



Thanks again.

 

[zizzer]

I don't think there are many bad programs, and personal work ethic will likely make the biggest difference in training. My point being to make sure you pick somewhere you think you and your family will be happy for four years.

Here are some of the factors to consider and what I think of them.

1. Location: As above, go somewhere you'll be happy. Some will say you should pick a place near where you want to work as an attending. It probably does help, especially if that area is competitive. That said, it's probably not necessary, especially if you trained at a program with a good reputation. Factor in salary and cost of living.
2. Reputation: Whereas you may get only slightly better training at a program with a good reputation, all else equal, it may dramatically help in your job prospects.
3. Workload: You do not want to go to a place that relies on you too much to get everything done. As a resident, you have a similar work role to CRNAs (working under attendings), so having CRNAs is really beneficial. Getting guaranteed time off weekly for lectures is huge. Working 50h a week is better than 60+. The extra hours of experience are not worth the crunched time you have for life, sleep, family, and studying.
4. Challenging cases: You want challenging cases. Programs without challenging cases will say things like, "even routine cases are educational" and "you don't want to do all 'zebra' cases." These should be red flags. You want to see every situation possible and how the attending handles it as a resident before you're an attending responsible for managing it yourself.
5. Autonomy: Getting to do more management without attendings breathing down your neck is helpful, but if you end up with overbearing attendings, it's ok as long as you challenge yourself to decide what you would do before they tell you to.
6. Residency size: Not a huge factor either way, but I liked being a big residency program. It's nice to have the opportunity to meet more friends and also build a bigger network for future career opportunities. I don't think getting lost in the crowd is much of a concern in a class of 20-30 people if you're still working with the same attendings for 4 years.

 

[Katheudontas parateroumen]

Great reply from @zizzer . I think somethings to also consider in terms of training is:

1. What are the roles of fellows? Is the place you're looking at have fellows? I think in general as a resident you want to be in the big cases. Some places have no fellows in certain areas which means you'll do all the cases but also may mean they don't have enough of those types of complex cases to go around. Probably most common issue in cardiac.

2. In terms of autonomy, i think it's good to have some level of learning how to run the board or be senior in charge. It's good to learn how to manage multiple rooms, staffing, supervising junior residents, etc.

3. Elective time in your CA3 year. Things like TEE rotation, palliative care, blood banking, etc. CA3 year is to round out your education and let you experience deeper understanding of your area of interest. Don't want CA3 year just be a repeat of CA2 year.

Location is honestly the most important factor as that's huge for your wellness which in turn makes you a better resident. I usually say, pick the most reputable program in the most desirable place you want to be. For example, if you really want to be in CA and have an interview let's say UCLA, Loma Linda, USC but you also have Hopkins, just pick UCLA (even if there's a perceived higher name for Hopkins). You get the best of being in the location you want and the name recognition for the area.

 

[Morzh]

Lots of good advice.

All accredited programs will lead to being a board-certified anesthesiologist, so long as you put in the work. Beyond that, it's all about what your priorities are.

Do you have a preferred geographic area that would make your 4 years easier, or that you want to end up in eventually? This is likely the single most important factor
If you have a spouse or significant other how do their priorities interplay with yours?
If you have a spouse, and especially if you have children, how much income do you expect your spouse to make during training... if your goal is to be the primary breadwinner on a trainee's salary then you seriously need to look at your expected cost of living and maybe give weight to programs known for generous moonlighting opportunities.
Do you like a strong didactic program (which usually means lots of mandatory lectures and sim labs), or do you prefer to just go home when the clinical work is over and study on your own?
Do you like research, QI, informatics or other non-clinical pursuits? Only a handful of programs are really strong in these areas... but if the thought of those things makes you nauseated then steer clear of places that are likely to force you to participate more than the bare minimum.
Do you have fellowship ambitions? It may be helpful to do residency at a place that offers the fellowship you're looking into - although this is definitely not a must. Conversely, there are advantages to a residency program not having certain fellowships - better cases for the residents.
What is your learning personality? Are you on the more timid/anxious side and prefer lots of guidance and coaching-up, or would you rather be "thrown to the wolves"? Resident autonomy can vary significantly from program to program. Those who prefer close mentoring may feel abandoned or resentful at a place that gives a lot of autonomy (having true autonomy is a lot of work!). Conversely, those who hate having their hand held will be miserable at certain ivory tower type places where your 1:1 attending is always breathing down your neck. Intra-op teaching is important, but often the best "teaching" is when your faculty leave you alone for several hours - sometimes literally letting you do the entire case solo from induction to PACU (more appropriate for a strong CA-2 or CA-3 level). I know of institutions that have blanket rules stating things like faculty must be present in the room for every extubation or must be present for every routine labor epidural placement. Personally I sought to avoid such places. Graduated autonomy, earned by strong performances over time, is crucial in training.

On prestige... there's nothing wrong with admitting that you value training at a prestigious place. Especially if you are interested in an academic career. The clinical training is generally not going to be significantly superior at these places (in fact sometimes it is worse), but the connections, mentors, and research opportunities (if you're into that) that exist at a top-10 type place don't exist everywhere. But realize there is a difference between "prestige" and "reputation". Many prestigious places actually have pretty mediorce reputations (among those in the know) in terms of the skill and competency of their average graduate. If your main priority is to simply be a bad-*** anesthesiologist who is comfortable with any case that comes through the door, then don't stress too much about academic prestige, especially if it's in conflict with other priorities like location. Many programs with "middle-of-the-road" brand names actually have very strong regional reputations due to reliably producing graduates who are clinically excellent.