Importance of residency/fellowship prestige

[Handinhand]

Current M4, going into orthopedics and on the interview trail right now -- taking a little bit of a break over the holidays and was hoping I could get some opinions on this.

What is the overall importance of residency & fellowship 'prestige' on future job prospects? Obviously if you want to be an academic orthopod at the Mayo Clinic, HSS, Harvard, etc... then going to a powerhouse residency and fellowship is probably the right choice. I'm more questioning the other positions -- either smaller academic programs, or non-academic hospitals/private practice? How about if you want to move to a different region after residency? Say you train at a smaller program in the midwest -- is it still feasible to compete for jobs out west or the north-east if you ultimately decide you'd like to go there?

Slightly related question -- does where you went to residency effect your fellowship options? I know this obviously plays a part; however, I've found on the trail this year that many applicants are coming from low to mid tier medical schools, but are pulling top-tier interviews due to a quality application (good step 1, AOA, research, etc..), even if their home program/faculty aren't incredibly well known. Is this possible with residency, to "move-up a tier" so to say, if you are a great resident, publish frequently, etc?

I ask because I've gotten competing advice from residents and faculty ahead me. Some are of the opinion that you should go to the "best" (aka, biggest name) residency possible, while others think you should go to the one you fit in with best. I just so happen to find myself fitting in better at the smaller programs -- but I feel like the devil is on my other shoulder echoing the words of those faculty and residents saying that I should try and go to the big name academic programs.

I wanted to post this and ask because I know from talking with many other applicants that they have the same concerns and questions, and I haven't found it answered well here or orthogate.

Thanks for any advice.

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[Sam212]

I'm still a resident so take it with a grain of salt. I come from a small community program so my experience may be different. I have spoken to many of my senior residents and our graduates and other attendings about this. Most of these people ended up in private practice in various parts of the country, just so you know the context. I have asked this very question. By and large, the answer I received was that if I am going to invest in a fellowship, make sure it's a hands on fellowship where I get to operate a ton. A lot of prestigious fellowships also are operating heavy so that's probably a no brainer. However, there are many prestigious fellowships that are pretty much glorified observerships. In fact we have a couple of attendings that attended such fellowships and said they wouldn't do it again.

The other issue, from the community side of things, is the complexity of cases in some of these prestigious fellowships. You are asked to do many research projects and get involved in unique complex cases that are rarely seen in the community private practice. The advice I received was to attend a fellowship that'll provide variety of community as well as complex cases to get a good experience.

Of course, this advice is for someone who wants to do community private practice orthopedics and just wants to be a great surgeon. If you want the higher academic pedigree, then you'd definitely be better off doing those prestigious fellowships.

My program, while a small community program in the Midwest, sees a ton of general community stuff. We operate early and often compared to most other programs. It's not unlikely for our graduates to do general orthopedics because of the experience we get. In fact about 35% of our graduates in last 10 years have done general orthopedics. So it really depends what you want. If someone wanted to be an attending at ivory towers from our program, they'd have a hard time and will surely need a very prestigious fellowship, if not two.

 

[Follow the Cairns]

My husband finished his residency 10 years ago and has been in practice in all 3 of the major types of practice models since (5 years in private practice in a small group; 3 years in academics as an Assistant Professor, and, currently in a hospital employed position in a large system).

His residency was not in a prestigious program, his fellowship, however, was. Never once in that entire time (including the academic position) did anyone care where he did his training. He does Foot and Ankle, which is very much in demand, so finding positions has been very easy to do. I suppose there is some degree of self selection at play here, as he has never been interested in seeking a position in a highly academic environment where credentials such as training would be a major consideration.

But, honestly, in our experience (and the experience of most of our friends), recruiters, partners and hospitals don't care where you trained, as long as you are BE/BC and have no skeletons in your closet. And patients, by and large, don't even understand what residency is, let alone what programs are good, bad or indifferent.

 

[Handinhand]

1) Most of these people ended up in private practice in various parts of the country, just so you know the context. I have asked this very question.



2) A lot of prestigious fellowships also are operating heavy so that's probably a no brainer...... Of course, this advice is for someone who wants to do community private practice orthopedics and just wants to be a great surgeon. If you want the higher academic pedigree, then you'd definitely be better off doing those prestigious fellowships.... If someone wanted to be an attending at ivory towers from our program, they'd have a hard time and will surely need a very prestigious fellowship, if not two.

I pared down your post a little bit, but I wanted to ask a little further about this.

1) So even coming from a community program in the mid-west, you feel like graduates of your program, and programs like it, still have an opportunity to get out of the midwest? I'm by no means committing myself to leaving the midwest -- I was born and raised here and love it, but if later on I decided I wanted to move out west, or to the north-east (like Vermont, Maine, and New Hampshire, not large east coast cities like Boston and Manhattan) I would like the ability to do so.

2) Do you think it's still possible to get those 'higher end' fellowships coming from a smaller community program? Again, I likely won't be shooting for sports at HSS, I'm just curious if going to a smaller program sets you up to only go to a similar fellowship and future career? It's really hard to get a sense of this, because I feel like some of residents of smaller programs CHOOSE to go to similar fellowships (To paraphrase a chairman at one of my interviews "I sometimes questions the places some of the residents go to for fellowship, but they are all going to where they want"), but then I've heard residents say they didn't get fellowship interviews to places they were interested in.

Kind of a side question, what makes someone a competitive applicant for fellowship? Since there's no Step 1, class grades or all of that other non-sense that we are measured against as medical students, what are programs looking at in residents for fellowship? Is it mostly the who-knows-who system among faculty members? Research?

Again, my number one priority is picking a residency that will allow me to become a great orthopedic surgeon after 5 years, and hopefully in a location and with classmates that I really enjoy. I'm asking these questions because fellowship is becoming a more and more mandatory thing in Orthopedics, and I think it needs to be at least a consideration in choosing a residency, but is something that gets glossed over at almost every interview I've been on.

Thanks again for all the help.

 

[Sam212]

I pared down your post a little bit, but I wanted to ask a little further about this.

1) So even coming from a community program in the mid-west, you feel like graduates of your program, and programs like it, still have an opportunity to get out of the midwest? I'm by no means committing myself to leaving the midwest -- I was born and raised here and love it, but if later on I decided I wanted to move out west, or to the north-east (like Vermont, Maine, and New Hampshire, not large east coast cities like Boston and Manhattan) I would like the ability to do so.

2) Do you think it's still possible to get those 'higher end' fellowships coming from a smaller community program? Again, I likely won't be shooting for sports at HSS, I'm just curious if going to a smaller program sets you up to only go to a similar fellowship and future career? It's really hard to get a sense of this, because I feel like some of residents of smaller programs CHOOSE to go to similar fellowships (To paraphrase a chairman at one of my interviews "I sometimes questions the places some of the residents go to for fellowship, but they are all going to where they want"), but then I've heard residents say they didn't get fellowship interviews to places they were interested in.

Kind of a side question, what makes someone a competitive applicant for fellowship? Since there's no Step 1, class grades or all of that other non-sense that we are measured against as medical students, what are programs looking at in residents for fellowship? Is it mostly the who-knows-who system among faculty members? Research?

Again, my number one priority is picking a residency that will allow me to become a great orthopedic surgeon after 5 years, and hopefully in a location and with classmates that I really enjoy. I'm asking these questions because fellowship is becoming a more and more mandatory thing in Orthopedics, and I think it needs to be at least a consideration in choosing a residency, but is something that gets glossed over at almost every interview I've been on.

Thanks again for all the help.

I understand you don't want to shut any doors.

To answer your questions:

1) two of our recent graduates have gone out west, one in probably the most competitive market in Bay Area, another in seattle. Both were able to find jobs. Most of our graduates are from the Midwest and hence tend to stay, but we have graduated everywhere, including NoCal, SoCal, Northeast, Miami, even Denver, CO. I think there are jobs available in every area, some of which may be more hard to attain coming from a smaller unknown program, but if you are hell bent on going to a specific area, you'll find something, even general. You'll just have to likely take a pay cut.

2)since we are not very research heavy, most of our guys don't wanna go to high powered research fellowships. Most guys coming out of our program want to do community orthopedics. There are a couple of guys that did academic, one of them is in sports, another in foot and ankle, they both had high powered fellowships. But foot and ankle and sports are easy matches. However, we have also had guys recently match into Rush/ROI/Emory for Joints and cinci/Louisville/Indiana for hand. Those are probably the most competitive fellowships and pretty decent names in respective fields.

Of course no one has done Vail or HSS for sports or Ortho Carolinas for trauma, but I am not sure if anyone even wanted it. Seems to me most guys are content with their matches. I don't know what a competitive fellowship is. To me a good fellowship is that lets me operate and makes me a good surgeon, so when I'm on my own, I feel comfortable doing whatever it is I want to do. That's my ultimate goal, to become a great surgeon and operate like a boss, everything else is fluff to me. But to each their own, I am sure someone coming out of an ivory tower would probably contest what I said, and that's ok because that's not where I aspire to be, I'll likely end up in the Midwest doing community orthopedics, for which I believe I'm very well trained.23198898

 

[Sam212]

for your last question, my understanding is fellowships really put emphasis on your LOR and people you know. So in that case, going to a prestigious program with big name faculty may be worth it. They can go to bat come match time and make some calls which would undoubtedly have an huge impact.

Being at a smaller program, I don't have that luxury of course, but you'd still get a darn good fellowship in your chosen field. There are plenty of good fellowships around.

One more thing to add, job market in competitive areas is also about what subspecialty you're in. If you're a foot & ankle/hand/spine guy, you can pretty much walk into any area in the country, regardless of where you did your resodency or fellowship. Of course you may have some trouble in finding prestigious academic jobs but all private practices/community hospitals are looks for these subspecialties. Whereas, if you did a sports/trauma/joints fellowship, you opportunities in saturated areas may not be as plentiful, that's not to say you won't find something, but you'll likely take a pay cut/compromise on lifestyle, etc.

 

[orthojuniorfaculty]

A piece of general advice that was shared with me seems to hold true: "The name on your badge/diploma/white coat might help you with the NEXT step, but not necessarily much more."

As in, being in a so-called elite university has advantages for getting into medical school or getting a consulting job. Being in a top 10 medical school probably has some advantages with getting your foot in the door at a residency. Being at a residency with high name recognition and respect for providing good training (importantly, WITHIN the orthopaedic community, not with the general population - two very different things) likely helps with going to a fellowship of your choice, and being at a big-name fellowship (probably both with general name recognition but still more important that the orthopaedic community respects it) likely helps with landing that job you want in the location you want.

However, once you have that first job, your future prospects depend more than anything on what your colleagues and patients think, and if in academia on what you produce. Even before that, if you want to a big name medical school but then fall flat in residency don't count on coasting in to your top choice fellowship. Perhaps unfairly, I can think of cases where a person was able to effectively 'cash in' the name on their badge/diploma to have a leg up on the next step in the process - but that chip really can only be spent once. Especially once you have your first job, you will largely be judged by your actions and inactions.