How much does schedule in residency matter for preparedness

[Coltuna]

Hello all,

Applying IM and working on my rank list. I'm wondering how much schedule should play into my decision as it pertains to preparedness post-residency. For reference, I'm pretty sure I want to pursue hospital medicine. There are a few programs I've applied to that seem to have an amazing schedule on paper, but I don't want the schedule to impede my preparedness. For example, one program has a 4+4 (4 weeks of inpatient followed by 4 weeks out outpatient) schedule which seems awesome with regards to quality of life; however, will that quality of life come at the detriment of not being as prepared as a hospitalist?

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[MadRadLad]

Overall not that much. I mean, try to tailor your program to your goals if possible, but as long as you have enough inpatient exposure (hard to imagine you won't as an IM resident) all the small details will probably be smoothed out by the time you're a few months into practice. If there is a specific skillset you want to learn then you might want to go to a program that does a lot of that.

 

[Coltuna]

Overall not that much. I mean, try to tailor your program to your goals if possible, but as long as you have enough inpatient exposure (hard to imagine you won't as an IM resident) all the small details will probably be smoothed out by the time you're a few months into practice. If there is a specific skillset you want to learn then you might want to go to a program that does a lot of that.

So you don't think that spending half my time on outpatient for the 4+4 program will *really* matter? I know there are certain benchmarks/requirements for all IM residencies, so I kind of assumed it wouldn't affect me THAT much but wasn't sure!

 

[Redpancreas]

Hello all,

Applying IM and working on my rank list. I'm wondering how much schedule should play into my decision as it pertains to preparedness post-residency. For reference, I'm pretty sure I want to pursue hospital medicine. There are a few programs I've applied to that seem to have an amazing schedule on paper, but I don't want the schedule to impede my preparedness. For example, one program has a 4+4 (4 weeks of inpatient followed by 4 weeks out outpatient) schedule which seems awesome with regards to quality of life; however, will that quality of life come at the detriment of not being as prepared as a hospitalist?

I've experienced both traditional and X>>Y schedules in training for a significant duration of IM residency.

Neither provides a significant difference in the training of the physician in my opinion. The X>>Y is more comfortable and guarantees you golden weekends and a (hopefully) lighter week every Y week allowing you to reset mentally/physically. There is a lot of wasted time/fluff on the Y week though which can drag on. Traditional scheduling is not the giant evil every X>>Y program makes it out to be on interview day. Yes, you're seeing hospital patients on clinic days, but it's not that much more work and it presents a unique challenge of having to manage clinic patients with hospital ones which many attending physicians have to do. That said it's a skill you can learn quickly coming from an X>Y program.The issue with the traditional program is if the program isn't careful, you can run into a string of 6 week workdays for a long time which contributes heavily to burn out. If you design traditional just right it can mimic the advantages of X>>Y any maybe some places do that but X>>Y guarantees you some degree of wellness with those guaranteed goldens and lighter weeks. I also think the hybrids like 4+4 (X=Y) are good too.

If I were to choose, I'd choose X>Y or X=Y just for the convenience it assures you, but I wouldn't be as turned off by the traditional schedule or let that serve as a con to trump more important factors like location, prestige/name, training at any of the programs you're considering.

[Tangent] If you're looking for scheduling differences, I'd focus more on what the night situation is like because I think that makes a much bigger difference in wellness. Are there any qX 28H calls, dedicated night float, a mix, etc.? qX night call on medicine rotations is unnecessary in my opinion and adds nothing to training IMO other than elevated cortisol. A program I was in had the 28H calls on certain primary rotations and it ruined my circadian rhythm for the entire rotation. There's really no need for that and it doesn't prepare you for an intense schedule if you plan on going ICards or worried about GIB call. It just puts more mileage on your body. There's really no difference in continuity or educational value in finding out the LR gtt you started your frail old lady on with cellulitis in the day gave her pulmonary edema during the night from the night team vs. finding out on call. You'll be equally as motivated. One could make the marginal argument that your team (likely a quarter of your patients) are covered better since you are on call for your primary patients but then the other 3/4s are just normal. If I had my way, I would say no 28H call, just go with 7am-5pm day coverage with a long call and make the dedicated night float 7-7. I see some in med ed making the argument that the hardship of a 28H call provides you makes you stronger, but I think that's just BS as I find it no easier at a program that just does dedicated night floats now, but I am more awake. There's no reason to manufacture reasons to be resilient.

Just my thoughts. PM if you want more details.

 

[Redpancreas]

So you don't think that spending half my time on outpatient for the 4+4 program will *really* matter? I know there are certain benchmarks/requirements for all IM residencies, so I kind of assumed it wouldn't affect me THAT much but wasn't sure!

It won't matter. You will adapt to your post-residency life accordingly.

 

[Coltuna]

I've experienced both traditional and X+Y training for a significant duration of IM residency training.

Neither provides a significant difference in the training of the physician in my opinion. The X+Y is more comfortable and guarantees you golden weekends and a (hopefully) a lighter week every Y week. There is a lot of wasted time/fluff on the Y week though which can drag on. Traditional scheduling is not the giant evil every X+Y program makes it out to be on interview day. Yes, you're seeing hospital patients on clinic days, but it's not that much more work and it presents a unique challenge of not having to manage your clinic patients with hospital ones which many attending physicians have to do. That said it's a skill you can learn quickly coming from an X+Y program. If you design a traditional just right it can mimic the advantages of X+Y.

If I were to choose, I'd choose X+Y just for the convenience it assures you, but I wouldn't be as turned or let it trump location, prestige/name, training at any of the programs you're considering. If you're looking for scheduling differences, I'd focus more on what the night situation is like. Are there any qX 28H calls, dedicated night float, a mix, etc.? qX night call on medicine rotations is unnecessary in my opinion and adds nothing to training IMO other than elevated cortisol. A program I was in had the 28H calls on certain primary rotations and it ruined the schedule for the whole rotation. There's really no lost continuity or education value in finding out the LR gtt you started your frail old lady on with cellulitis gave her pulmonary edema from the night team vs. finding it yourself. Just my thoughts.

PM if you want more details.

This is really helpful. Thank you!

 

[mrbreakfast]

Short answer: it won't matter. If you want to be a hospitalist, you should be more than fine from whatever inpatient exposure you get. I'd be more concerned about exposure to adequate volume/complexity to prepare you for anything, but wouldn't sweat it. You can always check the "recent graduates" sections on residency websites to see how many people (if any) went directly into inpatient practice at a particular program.

When I was applying for residency, I made a spreadsheet comparing different program's schedules over each of the years. I'm in neurology, which has similarities to medicine, though there is more variation between schedules/inpatient-outpatient split. I knew there were certain things I was looking for (e.g. early elective time, a schedule that wasn't insanely front-loaded, dedicated time for EEG) and putting it all down on paper can make comparing program schedules a little easier. You might be surprised how different some programs do things.

Also, keep in mind that months on end of inpatient will make anyone go completely insane. No matter how inpatient-focused you are, you're going to need those occasional outpatient blocks.

Finally, many medicine programs have hospitalist electives (i.e. a single resident and attending managing a full general medicine list) which is always an option if you want additional inpatient reps.

 

[Cranjis McBasketball]

Short answer: it won't matter. If you want to be a hospitalist, you should be more than fine from whatever inpatient exposure you get. I'd be more concerned about exposure to adequate volume/complexity to prepare you for anything, but wouldn't sweat it. You can always check the "recent graduates" sections on residency websites to see how many people (if any) went directly into inpatient practice at a particular program.

When I was applying for residency, I made a spreadsheet comparing different program's schedules over each of the years. I'm in neurology, which has similarities to medicine, though there is more variation between schedules/inpatient-outpatient split. I knew there were certain things I was looking for (e.g. early elective time, a schedule that wasn't insanely front-loaded, dedicated time for EEG) and putting it all down on paper can make comparing program schedules a little easier. You might be surprised how different some programs do things.

Also, keep in mind that months on end of inpatient will make anyone go completely insane. No matter how inpatient-focused you are, you're going to need those occasional outpatient blocks.

Finally, many medicine programs have hospitalist electives (i.e. a single resident and attending managing a full general medicine list) which is always an option if you want additional inpatient reps.

Ive heard neurology is the worst residency so kudos

 

[Coltuna]

Awesome, thank you all for the responses! As I make my list, I'm realizing that quality of life is definitely at the top for me-- moving places with the 28 hour call down, prioritizing X + Y, etc. My other question pertains to quality of life vs prestige-- I did interview at a few larger academic institutions, but I'm realizing that they're really only so high on my rank list because of their name. If I do want to be a community hospitalist, how much going to a newer program over a large academic program hurt me?

 

[MadRadLad]

Awesome, thank you all for the responses! As I make my list, I'm realizing that quality of life is definitely at the top for me-- moving places with the 28 hour call down, prioritizing X + Y, etc. My other question pertains to quality of life vs prestige-- I did interview at a few larger academic institutions, but I'm realizing that they're really only so high on my rank list because of their name. If I do want to be a community hospitalist, how much going to a newer program over a large academic program hurt me?

Variable depending on the competitiveness of the location. The benefit of the academic program is that they tend to be larger and thus have a bigger network of alumni. Also if you end up being interested in a fellowship or a competitive gig somewhere the academic name matters a lot more in IM than many fields. Also being able to network with more subspecialists, etc.

 

[mrbreakfast]

I did interview at a few larger academic institutions, but I'm realizing that they're really only so high on my rank list because of their name.

Just make sure whichever places you consider heavily will have plenty of acuity and complexity. Being at an academic center means getting transfers other hospitals can't take care of. You don't want to go somewhere where patients are getting transferred away. This doesn't mean you'll necessarily have constantly to take care of those super-sick patients in the community, but you should at least be comfortable with the liver bombs, GI bleeds, ARDS patients, etc, if they come in.

 

[Redpancreas]

Awesome, thank you all for the responses! As I make my list, I'm realizing that quality of life is definitely at the top for me-- moving places with the 28 hour call down, prioritizing X + Y, etc. My other question pertains to quality of life vs prestige-- I did interview at a few larger academic institutions, but I'm realizing that they're really only so high on my rank list because of their name. If I do want to be a community hospitalist, how much going to a newer program over a large academic program hurt me?

I think you want to keep your options open. Name definitely matters all else being equal. I would stay away from newer programs in general. The organizational framework is not guaranteed to be there and you don't want to get screwed over by some wrinkles the leadership needs to iron out. Ignore the special efforts on interview day. There's a reason they're trying harder than others.

 

[Redpancreas]

Just make sure whichever places you consider heavily will have plenty of acuity and complexity. Being at an academic center means getting transfers other hospitals can't take care of. You don't want to go somewhere where patients are getting transferred away. This doesn't mean you'll necessarily have constantly to take care of those super-sick patients in the community, but you should at least be comfortable with the liver bombs, GI bleeds, ARDS patients, etc, if they come in.

One interesting paradox I've noticed is that while quaternary academic programs are amazing for many reasons, they sometimes suffer from bread-and-butter deficiency. You need to first learn the normal before you start seeing patients that require super-specialized care. That said, most established programs find a way around this by providing opportunities at satellite campuses where you can see that bread and butter. I'm not saying one should choose a non-quaternary center for this reason, but it's something to note.

 

[mrbreakfast]

One interesting paradox I've noticed is that while quaternary academic programs are amazing for many reasons, they sometimes suffer from bread-and-butter deficiency. You need to first learn the normal before you start seeing patients that require super-specialized care. That said, most established programs find a way around this by providing opportunities at satellite campuses where you can see that bread and butter. I'm not saying one should choose a non-quaternary center for this reason, but it's something to note.

Point well taken, but as you said, I think most programs find a way around this. For example, where I did my medicine year, IM residents rotated both at the main hospital, where everyone had 10 problems, and at a VA, which was full of bread-and-butter cases (uncomplicated COPD exacerbation, new afib, diabetic osteo, didn't take my lasix and now I'm swollen, etc).