Indicators of program malignancy?

[medicienne]

I am in the middle of interviews and wondering how best to find out if a program is malignant on the day of the interview. Since everyone is in their best behavior, it's more difficult than I thought. Everywhere I go the residents will say they are happy, which seems like a formality now.
Is it okay to ask if any resident has been fired or how they deal with a resident got into trouble for any reason?

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[Law2Doc]

I am in the middle of interviews and wondering how best to find out if a program is malignant on the day of the interview. Since everyone is in their best behavior, it's more difficult than I thought. Everywhere I go the residents will say they are happy, which seems like a formality now.
Is it okay to ask if any resident has been fired or how they deal with a resident got into trouble for any reason?

You won't find this out on interview day. No point asking questions which won't be taken in a positive light. What you have to do is (1) contact alumni from your med school you know who can give you the inside scoop, or (2) find a mentor in the field who knows the chairman/program director and various faculty. Malignancy starts from the top down, so folks can usually tell you that if the PD or chairman is a mean SOB who treats his colleagues poorly, then you might not want to be a resident there.

 

[njbmd]

I am in the middle of interviews and wondering how best to find out if a program is malignant on the day of the interview. Since everyone is in their best behavior, it's more difficult than I thought. Everywhere I go the residents will say they are happy, which seems like a formality now.
Is it okay to ask if any resident has been fired or how they deal with a resident got into trouble for any reason?

Resident firings are not necessarily an indication of a malignant residency program. If you have one or two programs that you really liked but want the inside scoop, go back for a second look. Ask if you can spend the entire day with one of the interns and do this.

If they refuse, you might want to avoid that program. You actually can get a pretty good vibe based on a second look. Things that are most important in a residency program are where the graduates end up (fellowships/private practice), pass rate for specialty boards (if there are many retakes, avoid) and what the educational resources are like (conferences, mortality and morbidity, lectures, grand rounds and case presentations). If the academics are poor/non-existent, you don't want to be there no matter how sweet the residents are.

A second look also affords you greater time to see the intern in action. Can you picture yourself in that situation in a few short months? Do they have support from the more senior residents? Support from the attendings? Ask about the call schedule (how many folks covering how many patients after hours) and how the various services are generally run. Are there opportunities for away electives? What about research opportunities?

 

[LadyGrey]

With everyone on their best behavior most places, programs where they aren't do stand out when you hit them. I've had residents admit to being less than thrilled at where they wound up, even if it's couched in unconvincing "well, this wasn't one of my top choice, but now I'm glad I'm here."

 

[peerie]

Well, I think some of it is personal choice and some of it is the program. I mean, you might not fit in with a group of granola liberals and so that would be malignant for you. The opposite is also true.

There are so many variables that enter in, like is this a super competitive field and are you willing to just go anywhere? verus do you really want to feel comfortable? Is this general surgery or FM? Urban or community? Other than that stuff, I say do what others suggest and look for strong learning, good upper level support; faculty are very supportive and interactive or are they remote and even hostile? You laugh, but I had someone insult a previous researcher I worked for and at a luncheon table with residents and other faculty. Not good! I have seen some really excellent teaching schedules and a couple with just a nod towards any teaching. I have also seen incredibly happy residents and some that looked terrified.

I think most importantly listen carefully throughout the day, watch closely and trust your instincts - that gut feeling that says "I feel safe" or "I don't feel safe." You don't always have to know why you don't feel safe, just trust the feeling. I don't think people are that good at hiding their feelings, and the bad stuff usually leaks out anyway.

 

[Law2Doc]

Well, I think some of it is personal choice and some of it is the program. I mean, you might not fit in with a group of granola liberals and so that would be malignant for you.

Your not liking it for personal reasons does not fit into the definition of what people mean when they say a residency is malignant. Malignant is where you get treated badly, abused (usually in terms of hours), and as a result, nobody is happy. If you are unhappy for personal reasons of your own, that doesn't make the program "malignant" as folks use the phrase.

 

[peerie]

Your not liking it for personal reasons does not fit into the definition of what people mean when they say a residency is malignant. Malignant is where you get treated badly, abused (usually in terms of hours), and as a result, nobody is happy. If you are unhappy for personal reasons of your own, that doesn't make the program "malignant" as folks use the phrase.

I disagree. If you are a liberal person and you are in a very conservative program, by the nature of the program you might find yourself in a 'bad' position. Particularly if you are the only one.

The opposite can also be true. Malignancy is in the eye of the beholder.

 

[Law2Doc]

I disagree. If you are a liberal person and you are in a very conservative program, by the nature of the program you might find yourself in a 'bad' position. Particularly if you are the only one.

The opposite can also be true. Malignancy is in the eye of the beholder.

You can think that, but when people talk about residency programs being "good versus malignant" they aren't talking about it with respect to personal ideologies. They are talking about overall treatment of the residents. Treated badly = malignant. Not into the ideology = personal issues in an otherwise benign program. My point is you don't get to define it yourself. When people talk about a malignant residency program, it is a term of art, and reflects on the entire residency (for everyone), not just one individual's perception of it. There really are some malignant places out there, and you'd be miserable there whether you were conservative or liberal.

 

[Samoa]

You can think that, but when people talk about residency programs being "good versus malignant" they aren't talking about it with respect to personal ideologies. They are talking about overall treatment of the residents. Treated badly = malignant. Not into the ideology = personal issues in an otherwise benign program. My point is you don't get to define it yourself. When people talk about a malignant residency program, it is a term of art, and reflects on the entire residency (for everyone), not just one individual's perception of it. There really are some malignant places out there, and you'd be miserable there whether you were conservative or liberal.

I disagree. If you don't fit in with the other residents, you will be regarded poorly, and this will translate into poor evaluations for the same level of work. You won't be treated as well, and things will happen to you that wouldn't happen if you did exactly the same quality of work, but were well liked socially.

It's just how it is.

 

[Ludicolo]

Malignant program: abusive in terms of hours, scut, lack of support, lack of teaching, lack of respect from attendings. Towards all residents. They could care less if you fail/pass your boards. They view residents as cheap labor – that is all. They prey on fear. These programs do not foster teamwork. It becomes every resident for themselves. Residents become defensive, suspicious, lonely, depressed. But they are told to behave in front of the applicants, or in front of the RRC, and frequently do for fear of repercussions. Residents being fired is one thing. Residents quitting is quite another.

If you choose a program where you don’t fit in, and are miserable because of it, it doesn’t make the program malignant. You simply chose poorly.

 

[docB]

One red flag is if you never get an answer to the question you actually asked. For example:

Q: How are your ancillary services?
A: You learn to be self sufficient here.
Translation: You push your patients to CT scan.

Q: Is it hard to get consults?
A: We are strong patient advocates.
Translation: It's like advocating to pull teeth.

Q: Are the attendings approachable?
A: We value independence.
Translation: No.

 

[Dr. V]

If you feel like they are "hiding" residents ie you only see one or two residents and all the rest are unavailable, then look out. They are hiding them for a reason.

Another thing to look out for is if the residents don't get along well. You have to work with these people for the next 3-5 years. If there is constant strife/back biting in the program then it's hard to be happy there. That is it's own form of malignancy.

 

[Faebinder]

There is a way to find out the malignancy status of a residency but most people wont do it....

Believe in yourself and assess the affect vs. mood of the interns. You will be able to tell what is sincerely said and what is BS. They can't hide the lack of congruence.

 

[Law2Doc]

I disagree. If you don't fit in with the other residents, you will be regarded poorly, and this will translate into poor evaluations for the same level of work. You won't be treated as well, and things will happen to you that wouldn't happen if you did exactly the same quality of work, but were well liked socially.

It's just how it is.

I don't disagree with that statement -- I disagree that that fits the definition of a "malignant program". A malignant program isn't about one resident. It's a mistreatment of all the residents.

 

[DarthNeurology]

I disagree. If you don't fit in with the other residents, you will be regarded poorly, and this will translate into poor evaluations for the same level of work. You won't be treated as well, and things will happen to you that wouldn't happen if you did exactly the same quality of work, but were well liked socially.

It's just how it is.

I sort of agree with Samoa. While I think that there are truly malignant programs out there, i.e. all the residents don't like the program, usually because the work is frustrating due to some really mean attendings, there are programs that some residents hate and others love.

However, if you aren't on the same page as your team then the place will seem very malignant. I have rotated on services that I thought were pretty good as a student, while other students felt that the place was horrible. If you are with a similar group of residents/attendings in terms of temperment then you can go through hell with a smile on your face.

But even a relatively benign appearing elective can turn into hell if you are with people who don't gel good with you. I think this is independent of political affiliation really. I think that some people *want* residency to be hellish for the residents -some are residents who want a very tough clinical experience while others are attendings who want to sock it to residents. Other residents/attendings are social or operate in a very constrictive heirarchy and constantly have to maintain the pecking order and complaing about people not respecting them. Others times I think it is intangible factors which lead a person to just not get along with others.

I think an alternatively reasonable definition of a malignant program is one that is overly polarizing, i.e. some residents "love it" and look down on other residents who "hate it" and perhaps even left for whatever reason. When interviewing you will see programs that have a very specific way of doing things and want people like them because in the past some residents loved the program for their "intricacies" while others hate the program for what they viewed as unfair treatment or a poor environment. So no, I don't think that everybody has to hate a program for it to be branded malignant, if say 25% of residents *really* don't like a program and the rest love it, you run a chance that you might not like it. However, if a program has 100% of residents who think the program is "OK to good" then your worst case scenario is just giving the program an "OK."

So, to get a good feel for a program you have to really talk to ALL of the residents, and if you just see a couple very enthusiastic chief residents but no interns, well, they could be just happy to be finishing and you have to wonder why the interns are hidden. . .

For example, if 25% of the country thinks Bush is/did a good job as president and you just talked to them then you view would be very biased with people saying things like "All presidencies are hard and each president has a hard time and Bush is deep down a good president!"

I would be most concerned for those programs looking for a specific "fit" to their program, this is code for: "We have had problems with certain residents in the past who haven't been able to "fit" personality wise into our program although good clinicians and were given a hard time." If you have a PD telling you what type of resident won't fit in the program this should raise big red flags.

The BEST residency programs are able to work with ALL types of residents, i.e. they are flexible and don't need a special "fit" with residents. . . . Remember if programs have a problem with "fit" into their program it means that they had problems with residents in the past who didn't bend to their culture.

Really, the only way to know if you will fit is to do a rotation at your residency program, or given that you can't do that for all programs, then you need to have dinner with the residents and see if you basically are like them.

 

[Law2Doc]

While I think that there are truly malignant programs out there, i.e. all the residents don't like the program, usually because the work is frustrating due to some really mean attendings, there are programs that some residents hate and others love.

Totally agree with this above statement. However when you use the phrase "malignant program", most people are going to take it to mean a place that's bad to the residents. It's a definitional issue. I don't disagree that some folks are going to hate places that others love. But the point is there are places where folks are truly overworked (often in disregard to the rules), treated badly, and otherwise abused. Those are the "malignant programs" as that term is used. Among the other programs folks will have individual preferences. But your not liking an otherwise benign program doesn't make it a "malignant program". It just makes it a bad fit. It's an important distinction, because when you start using phrases like malignant residency program based on your own personal preferences, it makes it harder for folks inquiring about true malignancy to get a good read.

 

[dragonfly99]

Agree most w/samoa and peerie.
I think there are programs that most everyone would agree are malignant (i.e. mucho scut, horrible hours, lots of mean attendings, program probably filled w/FMG's because nobody else wanted to match there). Then there are other programs that have a very narrow range of personalities and social/political views that one has to have to "fit in" and the programs haven't figured out how, or haven't tried, to work with different types of residents and teach them effectively. At times, some programs I think evaluate the residents more on personality vs. medical judgment/treatment of patients. I would say those latter type of programs could be considered malignant also. I don't think one can say that "malignancy" is a totally objective thing, and it's not defined just by work hours or having attendings who are inaccessible and/or very unpleasant.

 

[DarthNeurology]

However when you use the phrase "malignant program", most people are going to take it to mean a place that's bad to the residents. It's a definitional issue.

I would say that malignancy is in the eye of the beholder. I have rotated at some pretty "malignant" places where maybe 40% of the residents have thought about quiting or did quit and left for another residency or came back later. However, I would assume that for every "truly malignant" program out there, in every such program there are residents who like the program or wouldn't call it malignant, maybe they like the macho scut work or something, or don't get harrassed by attendings as much. I don't believe that you can show me any residency program where ALL the residents absolutely 100% hate the program, . . . otherwise the program would lose half the class of residents every year.

There is no such thing as a program that is "absolutely malignant", according to who?? There are many people who would swallow their pride and change their personality into something very nasty to survive a malignant program that you would not consider going to.

It is a delusion IMHO to say that some programs are truly malignant and others only have a mixture of disgruntled residents and happy residents. Most programs have a vast majority of happy residents. Some programs that the the most/absolute malignant have more than their share of disgruntled residents who think the program is very bad, however, even at these places you will find chief residents and even interns who think everything is OK or bearable. Everybody has a different residency experience, even at the same program.

 

[thegunshow]

I usually start by asking the program if they have had any recent fever, night sweats, or unintentional weight loss.

 

[Winged Scapula]

If you feel like they are "hiding" residents ie you only see one or two residents and all the rest are unavailable, then look out. They are hiding them for a reason.

Another thing to look out for is if the residents don't get along well. You have to work with these people for the next 3-5 years. If there is constant strife/back biting in the program then it's hard to be happy there. That is it's own form of malignancy.

These are important points.

Residents who like their program will show up for the interviews, social hours to brag about their program and encourage candidates to rank them.

If only a few show up its either because:

1) the residents don't care
2) the residents cannot bring themselves to say good things about their program
3) or the program has chosen to hide them. Just like back in my sorority days (when we made the less attractive girls work in the kitchen), if there are members who will show a less than flattering aspect of your organization, it behooves you to hide them.

 

[Law2Doc]

I don't believe that you can show me any residency program where ALL the residents absolutely 100% hate the program, . . . otherwise the program would lose half the class of residents every year.
...
It is a delusion IMHO to say that some programs are truly malignant and others only have a mixture of disgruntled residents and happy residents. Most programs have a vast majority of happy residents. Some programs that the the most/absolute malignant have more than their share of disgruntled residents who think the program is very bad, however, even at these places you will find chief residents and even interns who think everything is OK or bearable. Everybody has a different residency experience, even at the same program.

While I agree with the notion that there will be people who are unhappy even at relatively benign places, that doesn't make the place malignant. That's where I think you cannot call it a "malignant program" because to do so misleads folks who are trying to figure out which programs are going to be generally (not personally) tolerable. So "malignant program" means something more than just a bad individual fit. As for saying that "most programs have a vast majority of happy residents", that simply isn't the case. Wish it was. There are some malignant places out there where most of the people are unhappy. And where people bail to other programs every year. And most mentors can tell you which places these are. And when they say, don't go there, I know the folks over there and it's a malignant program you don't want to go to, they aren't talking about one or two folks perceptions. They are talking about the program as a whole.

 

[peerie]

Oh my gosh! I totally agree with the saying: 'we are looking for the right fit' and having it mean "you better be a certain kind of way or else."

I totally had a few places say that to me, and not surprisingly these were the places were I felt something squinky about them. One place was very good, and I would be ok training there but I definitely realize that if I were to go there I would have to be a certain way. I could do it, but it would be a conscious behavior. The program itself was really excellent and the people were very kind, tho.

The best places I liked were the ones who had almost all the residents show up for the dinner the night before and who were very chill and easy going. Kind of liked they were glad to see me but didn't fall out of their chair for me. Very pleasant people who were open and honest and were mostly just curious about me and my interests.

Wow! these are awesome examples of what to look for on interviews. Keep 'em coming!

 

[3dtp]

Oh my gosh! I totally agree with the saying: 'we are looking for the right fit' and having it mean "you better be a certain kind of way or else."

I totally had a few places say that to me, and not surprisingly these were the places were I felt something squinky about them. One place was very good, and I would be ok training there but I definitely realize that if I were to go there I would have to be a certain way. I could do it, but it would be a conscious behavior. The program itself was really excellent and the people were very kind, tho.

The best places I liked were the ones who had almost all the residents show up for the dinner the night before and who were very chill and easy going. Kind of liked they were glad to see me but didn't fall out of their chair for me. Very pleasant people who were open and honest and were mostly just curious about me and my interests.

Wow! these are awesome examples of what to look for on interviews. Keep 'em coming!

Another thing to look at is the program completion rate. Depending on your specialty this could be a key indicator. FREIDA publishes this but this information comes from the programs and the programs have [gasp] been known to not tell the truth in these things. If the program doesn't have a 100% completion rate, then ask why not. Sometimes (OB-GYN) people get into it and have a change of heart and go into something else. Other times, there may really be an issue.

Find out the names of residents who have completed the program the year before and are not employed at the training institution and call them. The official program sources may have a few names on tap, but you are looking for an independent assessment. During the dinner party, ask a couple of the other residents for these names, write them down, find them and call them. You're more likely to get a candid assessment of a program from those who are relatively safe from retaliation.

They want your references, you should get theirs as well. In fact, now that I think about it, every resident candidate for every residency program should ask the program for references from recent and perhaps not so recent graduates. Then call them. They'd do it for/to you.

 

[Narmerguy]

Agree most w/samoa and peerie.
I think there are programs that most everyone would agree are malignant (i.e. mucho scut, horrible hours, lots of mean attendings, program probably filled w/FMG's because nobody else wanted to match there). Then there are other programs that have a very narrow range of personalities and social/political views that one has to have to "fit in" and the programs haven't figured out how, or haven't tried, to work with different types of residents and teach them effectively. At times, some programs I think evaluate the residents more on personality vs. medical judgment/treatment of patients. I would say those latter type of programs could be considered malignant also. I don't think one can say that "malignancy" is a totally objective thing, and it's not defined just by work hours or having attendings who are inaccessible and/or very unpleasant.

I disagree with this. If malignancy is used in this manner than it essentially means absolutely nothing. Someone can always be found that will find something distasteful or bothersome about a program. That's the nature of human diversity. "Malignancy" as a description is only useful when it applies in a way that, irregardless of one's unique personal prefrences, indicates a generally unbearable program.

 

[Law2Doc]

I disagree with this. If malignancy is used in this manner than it essentially means absolutely nothing. Someone can always be found that will find something distasteful or bothersome about a program. That's the nature of human diversity. "Malignancy" as a description is only useful when it applies in a way that, irregardless of one's unique personal prefrences, indicates a generally unbearable program.

My point exactly (but said much more clearly).

 

[Doowai]

One of my classmates who is in PMR now swears he went to an interview and the first resident he interviewed with told him not to come there, and the PD did not even bother to show up -so he left.

 

[NinerNiner999]

Ten signs your residency program is malignant:

1) The program director never puts down a cup of coffee. Ever.
2) Nurses give residents the stink eye when they are asked to deflate the foley balloon before removing it.
3) Residents cringe at the thought of Subway or Pizza.
4) The intern in the back room has a black eye.
5) The tech with the tattoos on his arm has a boxer's fracture.
6) The attending with blood stains on his white coat never looks you in the eye.
7) You hear an interview story that begins with "One day someone brought a goat into the ER."
8) The OR staff is very nice and friendly.
9) The department chairman tries to sit down but appears "uncomfortable" and prefers to stand.
10) People high-five each other when you leave the room.