IM Residency Training Program Tiers

[Phineus]

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We have all heard this, or some variation of it:

JHU, MGH, BWH, UCSF, Duke, and UPenn are top tier or Tier 1a
UMich, WashU, UWash, Mayo and Columbia are middle-top tier or Tier 1b
UAB, Vandy, Cornell, UTSW, BIDMC, UNC, and UCLA are bottom-top tier or T1c

I know this categorization is in no doubt strongly based on the USNWR "best hopitals/medical school" list, and also on the caliber of the fellowship placements of IM grads from these institutes (placements that are in turn also considered "solid" based on the USNWR data). My questions are about the truth behind these rankings:

(1)Imagine three individuals with an identical potential for becoming outstanding clinicians:

(a) Would there be significant difference in their clinical acumen at the end of residency if they individually went to UCSF vs WashU vs UTSW, or Duke vs Columbia vs BIDMC?

(b) If these three individuals are very driven and proactive in seeking out research, do Tier-1a institutes always offer better opportunities that T1-b/c?

(2) Are there certain teaching philosophies that contribute to where programs rank in these tiers (e.g. JHU is known for its autonomy, Duke is known for its EBMcentric curriculum)?

(3) Are these classifications too elitist and outdated as there are numerous solid IM training programs that are unheard of due their location or status as community programs?

Of interest: http://www.brimr.org/NIH_Awards/2008/NIH_Awards_2008.htm

 

[Scaredshizzles]

Some of the best clinicians I've ever met were at community hospitals. So obviously not. Status simply opens doors for you in terms of research and joining high level practice groups in medicine/subspecialties. It makes life easier, but obviously it doesn't guarantee success...On the other hand, certainly not being at one of these programs doesn't mean that all doors will be locked to you in the future, but you'll just need to turn the knob and push away on your own.

 

[Friendly]

Who cares!?! 20 different people will give 20 different answers about the "tiers". Bottom line: there are many ways to skin a cat.

 

[houstoncfh]

We have all heard this, or some variation of it:

JHU, MGH, BWH, UCSF, Duke, and UPenn are top tier or Tier 1a
UMich, WashU, UWash, Mayo and Columbia are middle-top tier or Tier 1b
UAB, Vandy, Cornell, UTSW, BIDMC, UNC, and UCLA are bottom-top tier or T1c

I know this categorization is in no doubt strongly based on the USNWR "best hopitals/medical school" list, and also on the caliber of the fellowship placements of IM grads from these institutes (placements that are in turn also considered "solid" based on the USNWR data). My questions are about the truth behind these rankings:

(1)Imagine three individuals with an identical potential for becoming outstanding clinicians:

(a) Would there be significant difference in their clinical acumen at the end of residency if they individually went to UCSF vs WashU vs UTSW, or Duke vs Columbia vs BIDMC?

(b) If these three individuals are very driven and proactive in seeking out research, do Tier-1a institutes always offer better opportunities that T1-b/c?

(2) Are there certain teaching philosophies that contribute to where programs rank in these tiers (e.g. JHU is known for its autonomy, Duke is known for its EBMcentric curriculum)?

(3) Are these classifications too elitist and outdated as there are numerous solid IM training programs that are unheard of due their location or status as community programs?

Of interest: http://www.brimr.org/NIH_Awards/2008/NIH_Awards_2008.htm

I think you know the answers to your own questions. I had a frank discussion with a senior faculty member at my school about the differences b/w my home program (definitely not on this list) and the programs you've listed above. He said from a training standpoint, you end up at pretty much the same place coming from any university or large community program. Research is available everywhere.

The major difference is that the quality of residents is fairly variable. I believe that the best handful of residents from say, Carolinas Medical Center, are just as good clinicians, etc as the top residents from Duke. But once you get to the bottom quartile of residents, you start to see the difference: these top tier programs are uniformly strong across the board, while there's some variability in the 'less prestigious' programs. (NOTE: my programs listed were just examples, not based on any real knowledge of the programs.)

I think from a training standpoint, you want to be constantly challenged (in a healthy way) by your peers.

 

[ResidentMD]

I think you know the answers to your own questions. I had a frank discussion with a senior faculty member at my school about the differences b/w my home program (definitely not on this list) and the programs you've listed above. He said from a training standpoint, you end up at pretty much the same place coming from any university or large community program. Research is available everywhere.

The major difference is that the quality of residents is fairly variable. I believe that the best handful of residents from say, Carolinas Medical Center, are just as good clinicians, etc as the top residents from Duke. But once you get to the bottom quartile of residents, you start to see the difference: these top tier programs are uniformly strong across the board, while there's some variability in the 'less prestigious' programs. (NOTE: my programs listed were just examples, not based on any real knowledge of the programs.)

I think from a training standpoint, you want to be constantly challenged (in a healthy way) by your peers.

This is what I have been told too.

Also with regard to clinical training, each program differs.

You will get the basic bare minimum to become a competent internist at the end of 3 years, but how much confidence you would have varies.

Everyone knows that Mayo and BIDMC are not as hands-on as say, UAB and UTSW (I havent yet visited Vandy). So while you become a competent internist, you may or may not be comfortable intubating, putting lines....now whether that matters to you or not, is another issue, and probably should be in your decision making point.

I believe the "prestige" of an institution plays a role in only a few areas-

1. Fellowship opportunities, but then you need to cover your a** by ensuring that you could at least have in-house as a security, if not more.
2. Making contacts and opening doors in academics.
3. In FELLOWSHIPS, the NIH grants are often scored based on the reputation of the institution and the people you work with, so that becomes an issue THEN (not largely, just a bit).

So what the poster above said, that for all practical purposes, you will get competent training, but the breadth and depth of the training may differ even within each tier, and the quality of your co-residents is something that may change as you move down the tiers.

 

[jdh71]

(a) Would there be significant difference in their clinical acumen at the end of residency if they individually went to UCSF vs WashU vs UTSW, or Duke vs Columbia vs BIDMC?

No. Pancreatitis, Pneumonia, and Chest Pain are not an institutional phenomenon.

(b) If these three individuals are very driven and proactive in seeking out research, do Tier-1a institutes always offer better opportunities that T1-b/c?

Probably no, not really, not practicaly speaking. If you want to do a fellowship at the "number 1" fellowship program in the country, then you do stand a better chance at a more elite program. But if you're simply interested in sub-specialty training somewhere, then no. No big difference.

(2) Are there certain teaching philosophies that contribute to where programs rank in these tiers (e.g. JHU is known for its autonomy, Duke is known for its EBMcentric curriculum)?

Not as far as I can tell

(3) Are these classifications too elitist and outdated as there are numerous solid IM training programs that are unheard of due their location or status as community programs?

Most definitely 👍

 

[Frugal Traveler]

(1)Imagine three individuals with an identical potential for becoming outstanding clinicians:

(a) Would there be significant difference in their clinical acumen at the end of residency if they individually went to UCSF vs WashU vs UTSW, or Duke vs Columbia vs BIDMC?

Perhaps. It depends on how you define significant. At the end of residency, I think programs do produce individuals with variable characteristics. At an end point 5 to 10 years out, clinical acumen likely equalizes because time and practice cures knowledge deficit.
You will hear attendings on the phone talking to OSH say:
"Oh, I trained at Duke. I can take care of this lung transplant."
"Oh, I trained at UCSF, I can handle anything."

I would say on your above list that UCSF, UTSW, and Duke get the hands down respect for clinical training.

Watching fellows go head-to-head is oftentimes interesting because certain schools typically produce fellows that are very good and can do procedures with great celerity. Other fellows sink initially but swim later after some experience they could have got at the other fellow's residency.

Some programs can coddle residents more and decrease their clinical abilities compared to peers.


(b) If these three individuals are very driven and proactive in seeking out research, do Tier-1a institutes always offer better opportunities that T1-b/c?

It is all about the host-guest relationship.
First, it depends on whether the individual has a specific interest and whether or not that institution can cater to it.

It is also analogous to bacterial growth. If an individual that is somewhat of a dud is placed on Harvard agar with innumerable nutrients, nurturing, and opportunities, that individual may fail to grow because they are innately a dud. If you place anyone from the mid-portion of their medical school class to AOA members, then you would probably get the near the same result (but the program often chooses the person with the highest achievement just for probability reasons although really anyone in your medical school class could succeed there with differing levels of initial effort).

You also have to consider that residency is primarily a clinical endeavor. Way to much effort these days has been placed on research and not taking care of patients during residency. Some residency programs have responded to this and become dedicated to producing great clinicians and having a scholarly requirement be done during the PGY-3 so as not to interfere with training. You can always do research after residency, so just be careful about pursuing too much during residency because you only get your basic training once.

(2) Are there certain teaching philosophies that contribute to where programs rank in these tiers (e.g. JHU is known for its autonomy, Duke is known for its EBMcentric curriculum)?

Johns Hopkins may be known for autonomy, but it did not get # 1 Hospital in USWNR for autonomy... rather patient safety among other variables (hospitals were scored on reputation, death rate, patient safety, and care-related factors such as nursing and patient services). The era of the "cowboy" in medicine has come to an end at most programs. This autonomy business may be a great myth because really you nearly always have back-up or help somewhere in the hospital while keeping your Aequanimitas steady so you can proudly wear a scarf or tie on Friday.
It oftentimes best to know what you do not know.

Various curricula produce different results. I think it is important to consider your learning style. The other issue is that most learning will probably take place while caring for patients.

A great didactic system can help organize your thoughts... so it is always something to consider.

Really try to get a sense of the program while you are there... ask yourself... would I thrive in this culture?


(3) Are these classifications too elitist and outdated as there are numerous solid IM training programs that are unheard of due their location or status as community programs?

People love to classify things. I think the programs you listed deserve to be recognized because they do represent some of the "best of the best" for internal medicine. Outside of these programs, there are a plethora of locations and other programs that serve students of internal medicine well.

Some community programs can be sweet deals and a veritable "separate peace" given that the combine the best of both worlds (great academics and clinical training in a less intense environment).

Bottom line: You get from residency what you put into it.

 

[HopkinsOslerDoc]

Johns Hopkins may be known for autonomy, but it did not get # 1 Hospital in USWNR for autonomy... rather patient safety among other variables ([/I]hospitals were scored on reputation, death rate, patient safety, and care-related factors such as nursing and patient services). The era of the "cowboy" in medicine has come to an end at most programs. This autonomy business may be a great myth because really you nearly always have back-up or help somewhere in the hospital while keeping your Aequanimitas steady so you can proudly wear a scarf or tie on Friday.
It oftentimes best to know what you do not know.

We're not Cowboys, we're Marines 🙂. Just kidding...

 

[Frugal Traveler]

We're not Cowboys, we're Marines 🙂. Just kidding...

You have one of the best hospitals in the world whatever you are

 

[Acherona]

The major difference is that the quality of residents is fairly variable. I believe that the best handful of residents from say, Carolinas Medical Center, are just as good clinicians, etc as the top residents from Duke. But once you get to the bottom quartile of residents, you start to see the difference: these top tier programs are uniformly strong across the board, while there's some variability in the 'less prestigious' programs. (NOTE: my programs listed were just examples, not based on any real knowledge of the programs.)

Which is why it's hard to say if people from top programs match well because they are just better on average, or because the program name helped them. There are always a handful of residents at mid-low tier programs that match at competitive places too. Also, some people just don't care that much about prestige (hard to believe, i know), and they might not rank places in SDN-order. Obviously you are more likely to find these people at less prestigious residences, and they are also more likely to care less about prestige for fellowship. So I find it difficult to believe that someone from a top IM residency with the exact same application as someone from a mid-tier residency (same board scores, research, recs) would really have that much of an advantage, especially after an interview. I mean are people that elitist?

 

[Acherona]

Johns Hopkins may be known for autonomy, but it did not get # 1 Hospital in USWNR for autonomy... rather patient safety among other variables (hospitals were scored on reputation, death rate, patient safety, and care-related factors such as nursing and patient services). The era of the "cowboy" in medicine has come to an end at most programs. This autonomy business may be a great myth because really you nearly always have back-up or help somewhere in the hospital while keeping your Aequanimitas steady so you can proudly wear a scarf or tie on Friday.
It oftentimes best to know what you do not know.

Exactly, hospitals are ranked based on what is good for the *patient*, not the resident. In fact good resident training may be in direct conflict with good patient care. This is why I find it odd how people use hospital rankings as evidence that the residency program is good. Where I went to med school, we were given ridiculous autonomy as med students (very little supervision, rounding and writing orders alone, doing procedures unsupervised, reading xrays by ourselves, carrying residents' pagers etc) and patient care definitely suffered because of it. But my classmates and I all had the same experience that we were extremely well regarded on our away rotations at other schools. So I think that autonomy can make a huge difference in terms of clinical skills and I don't see how many of the "elite" fellow-run private hospitals with VIP patients could provide this. I think they probably get away with it by having very bright residents.