Need Advice

[RnH723]

I am having some difficulty deciding between two residency programs. One program is located in an ideal location where I would like to be long term (it would be nice to build a contact base there). This program is not as well established but provides more flexibility in that I can create my own niche within the program. I won't have to conform to their rigidity. However, I do not feel that their didactics are as strong. Furthermore, they do not have a PM&R sports fellowship, which at this point, I intend to pursue. The second program is in my hometown and close to family, but not really where I want to be now or long term. It is more well established and they have strong didactics. However, I would not have as much flexibility within this program. Also, they have an ACGME PM&R sports fellowship. What it really boils down to is that I would prefer living in the location of the first program and I think I can create some good opportunities for myself there. Yet, I have questions about the didactics and exposure to MSK US. The second program is stronger but not in my ideal location. Plus, I wouldn't have much flexibility there. It is an issue of happiness/life outside of medicine and flexibility vs a more well established program with a sports fellowship. Do any current residents or recent grads have any advice for me? Since you are there now, what do you see as most important? Also, since I want to do a sports fellowship, is it better to go to a program that has a PM&R sports fellowship in house? Any advice or pointers would be much appreciated.

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[Spartyon]

Go wherever you can get the best training and if there is a fellowship you intend to pursue. I would go for the second option with the sports med fellowship. People move around all of the time it's worth it to go to the second place.

 

[DOctorJay]

Agree with sparty. Get the best training you can. PMR sports is super competitive with very limited spots. You will have first shot at your home program.

 

[Prof Moriarty]

Counterpoint: I depends on the program. Some residency programs have an attached sports med fellowship and there's very little trickle down in terms of its impact on your residency training. If you go there for that reason, I imagine it could be frustrating if it's not incorporated into your training. I would also look through their roster and see if they have traditionally taken people from in-house. There are some programs that like to do this, and there are others that prefer to look outside. Ironically, in some instances you might have a better chance coming from an outside program.

I also think that what programs look like on paper to you now may not turn out to be the way they are. Things tend to look good on the website/on paper, but the reality may be different. If you can talk to honest current residents at both programs, that will likely give you a better perspective.

Lastly, I can say that I would treasure some flexibility in my training. PM&R is a broad field and it's good to have broad exposure, but if you have a good sense of what you do and don't want to be doing, having the flexibility to build in your own mini-fellowship instead of spending 6 months doing something you know you'll never do again, that's worth something.

I wouldn't pick a clearly inferior program purely for location/networking/flexibility, but if it's a closer call, those things could play a role.

 

[RnH723]

Thanks for the responses. They are all very helpful. Please keep them coming. Also, if it means anything, the first option does have a primary care sports fellowship.

 

[MedBronc23]

Tend to agree with Sparty and DOctorJay. From my own personal experience, I faced a similiar question going into residency. PM me for more direct information. The short of my decision was choosing between my top 3 programs, knowing I wanted to pursue sports medicine or pain, or both. I think prof moriarity point is well-taken that some sports fellowships like to look outside the box, but if they do not keep you after they tried you for 3 years, than maybe its best for you and them. You still will get great exposure to the sports staff, build relationships for future, and likely land in another great fellowship (saw this with our chief resident who matched to sports at another predominant PM&R sports program (not same institution trained at). There are few accredited PM&R sports spots and hopefully more in future. I think the fear of being "inbred" that Prof Morality might be hinting at is a common fear when programs consistently keep their own, but converse it true of programs that look outside their residents. You make your own path with help from above. best to position yourself in a place that points you down the right road.

IMHO being at a place where you will be exposed to sports on a regular basis is key. My number one program ended up not being in my home state or my spouses home state, but it was where I felt I would get the good overall PM&R training, excellent outpatient training, exposure to PM&R sports and pain, and fellowship opportunities in both disciplines. You need to remember you will need letters of rec from sports medicine physicians for sports fellowship whether you choose primary care or PM&R. Often, it is hard to get electives if there is not a well-established sports or MSK department in your residency institution. Also, if it is primary care based, they may favor FP residents or more conventional primary care based residents (ER, IM, PEDS).

Also, if you are interested in sports and spine stuff, you will want to be at a place that will allow you hands-on with fluoro and US procedures. If you are interested in primary care sports and team coverage, you will want to be at a place that will allow you opportunities to cover events, teams, and do some longitudinal sports care in clinic. Remember sports fellowships want to see commitment to sports, participation in team event coverage. letters of rec from sports docs, opportunities for sports research (abstracts, posters, papers, ect.), and procedures if you can get them.

IMHO, the top places to train if you are interested in sports from a PM&R background are Mayo, Harvard/Spaulding, Washington, Emory, NW/RIC, UC Davis, Stanford, Wash U St. Louis, Med College Wisc (mostly womens athlete focus). All these have good ACMGE accredited PM&R sports fellowships with various exposure to spine, EMG, and US per my sources and experiences as student and resident in two of their programs.Tthere are 12 accredited PM&R spots fellowships but these come to mind.

Utah has very good and reputable Sports and MSK fellowship shared with Primary Care Sports Fellowship. Typically they take one ED, one FP/IM and one PM&R resident each year, and often another from one of those specialities if funding allotted. Can do emg, i-spine, and US with very good collegiate and olympic sports coverage.

Colorado has a unique PM&R Pain Fellowship that functions like a sports and spine fellowship and has sports event and team coverage opportunities. However, you can only be boarded in Pain from here now that grandfather rules for Sports CAQ exam require you complete a 1 year ACGME accredited fellowship.

Other primary care programs that are good and take PM&R applicants are Iowa (no associated PM&R residency, JPS in Arlington, TX (multiple PM&R programs in Dallas), U of Florida (takes 1 pmr and 1 PC), Mayo Jacksonville, Indiana, Michigan (combined track that PM&R can apply to), Cleveland Clinic ( Metro Health has PM&R residency).

There are lots more. These are just some that come to mind.

Try to position yourself for where you will get good training, good exposure to right patients, mentors, and skills. Living where you want is good too, but you can usually always go home if you have right connections, build your CV, and work hard at the right place.

Resources


http://www.aapmr.org/members/residents/newsletter/Pages/Resident-Newsletter-June-2012-Issue.aspx

http://www.amssm.org/FellowshipsPositions.html

 

[MedBronc23]

I would go with strong program with strong didactics and sports fellowship. Remember you have to pass PM&R boards before sports. You will always lean on a strong PM&R background on sports as well as most care is nonoperative. If your training base is faulty than you will be as well. You can carve out a niche anywhere if you are good and well trained

 

[Tromner]

In general, I think it's too early to be ranking fellowships when choosing a residency, right? You'll have to be prepared to apply to multiple fellowships and to move if need be anyway. I think presence of a fellowship is an indicator of a program's strength in a given specialty but I wouldn't choose a residency based on it. There are far too many factors that go into this decision to get to focused on one aspect.
I think that's why everyone talks about going with your gut and where you get the best feel. Whenever I write pro's/con's lists to make decisions, I end up over thinking it and getting something I didn't want. Residency is like a marriage. You wouldn't make a pro/con list for your spouse (or should I say, it wouldn't end well if you did).

 

[Paddington]

In general, I think it's too early to be ranking fellowships when choosing a residency, right? You'll have to be prepared to apply to multiple fellowships and to move if need be anyway. I think presence of a fellowship is an indicator of a program's strength in a given specialty but I wouldn't choose a residency based on it. There are far too many factors that go into this decision to get to focused on one aspect.
I think that's why everyone talks about going with your gut and where you get the best feel. Whenever I write pro's/con's lists to make decisions, I end up over thinking it and getting something I didn't want. Residency is like a marriage. You wouldn't make a pro/con list for your spouse (or should I say, it wouldn't end well if you did).

That's exactly the opposite of how you should be thinking.

In Internal Medicine (as well as other fields), people plan their whole residency application process based entirely on whether or not they want to do a fellowship, and which fellowships they want. There's some folks in PM&R thinking this way, but not nearly enough. I've seen a lot of senior PM&R residents scramble for pain/spine/sports fellowships. And unfortunately, musculoskeletal fellowships of all kinds at PM&R departments are few and far between for the huge number of residents pursuing these programs.

If your program has some kind of "pipeline" to a desirable (and ideally, ACGME accredited) fellowship, that's a huge plus. This could be if your department has its own fellowship, there's a friendly anesthesia program (or family medicine for sports) at the same university, or in town there's a good private practice based fellowship that's always taken folks from your program. You don't have to be a genius to figure it out; such programs will always take a resident or two, year after year.

Those programs are always going to take someone local, who they know, who they like, who did a rotation and/or an elective with them, over some outside candidate with similar credentials.

 

[RangerBob]

In general, I think it's too early to be ranking fellowships when choosing a residency, right? You'll have to be prepared to apply to multiple fellowships and to move if need be anyway. I think presence of a fellowship is an indicator of a program's strength in a given specialty but I wouldn't choose a residency based on it. There are far too many factors that go into this decision to get to focused on one aspect.
I think that's why everyone talks about going with your gut and where you get the best feel. Whenever I write pro's/con's lists to make decisions, I end up over thinking it and getting something I didn't want. Residency is like a marriage. You wouldn't make a pro/con list for your spouse (or should I say, it wouldn't end well if you did).

This is the advice that I am personally taking when it comes to choosing a program. However, at this point in time the fellowships I'm interested in are not all that competitive. But I think if you know you want to pursue a sports fellowships, it is indeed a huge advantage to go to a program with the fellowship. I used to coordinate the fellowship program (not in PM&R) at an unnamed top-10 university and the first thing the program director wanted to know was if there was any graduating residents who were interested in the fellowship. Many fellowship directors will prefer to work with people they know personally and could vouch for--otherwise they're depending on the recommendations of others, a list of qualifications, and a 30 minute interview to answer the "do I want to work with this person for a year" question.

 

[padresp]

Great reply, MedBronc.

The only thing I'll add to the mix is that I agree with Paddington on this. If you know (truly know) that you want to do a sports fellowship already, then do everything you can to set yourself up to succeed in that subspecialty. Just keep in mind that residents can change their minds, and you don't want to be stuck in a bad position if you're that person.

IMO, the point of residency is to prepare you for the next step, whatever that "step" may be. If you know already your next step, then plan accordingly.

 

[MedBronc23]

In general, I think it's too early to be ranking fellowships when choosing a residency, right? You'll have to be prepared to apply to multiple fellowships and to move if need be anyway. I think presence of a fellowship is an indicator of a program's strength in a given specialty but I wouldn't choose a residency based on it. There are far too many factors that go into this decision to get to focused on one aspect.
I think that's why everyone talks about going with your gut and where you get the best feel. Whenever I write pro's/con's lists to make decisions, I end up over thinking it and getting something I didn't want. Residency is like a marriage. You wouldn't make a pro/con list for your spouse (or should I say, it wouldn't end well if you did).

Almost totally disagree.

1. It's never to early to think about your future whether residency or fellowship. Ranking things on paper or in your head and its human. We all place value differently and ranks help guide decisions even if unconsciously. Better to be conscious about your residency rank list though

2. Yes, you will have to prepare to not stay at same institution city or state as residency for fellowship, but discounting the advantage of having a fellowship of interest around it associated with your program seems foolish. I agree that focusing on how great a fellowship is in choosing a residency may not always work out. However, in the case of my institution a strong Sports program exists because of a strong PM&R and Ortho department and both ortho and PM&R sports fellowships are strong because of the strength of their parent departments.

3. Looking a pros and cons for any choice is healthy whether in writing or in your head. I think it can shed clarity and show subtle differences when two choices are clear. Often, it comes down to a gut or heart feeling, which is usually the place that you will be happy. Having that unexplained "it" factor whether its in your spouse or residency can be powerful. I kid you not that my wife woke up from a dream one night and said "we are ranking this place #1". It was not our geographic choice or the place that would be easiest, but it had the best training and that feel good this is the one program. I could not be happier we made that decision, but it was much easier having looked at all programs intellectually before looking at them emotionally. Finding that balance between looks good on paper and feels good in heart usually leads to good training experience.

Btw I could make a pros cons list about my wife, but I would not ever write down. That's just dumb and grounds for badness, wailing and gnashing of teeth however, my list would have exponential pros and mirror that it feeling in my heart. Residency is like marriage for 3-4 years, and fellowship is like having a child. If you marry poorly and overlook red flags you might end up with unhappy results, which isn't so different from all aspects of life.

It's 5:44 am so ill stop babbling. Tromner mostly off base Paddington mostly on base from my perspective....

 

[Tromner]

In terms of pro/con lists, I just don't think that people are very good at them. They work fine for deciding on your top 3-4 programs, like a checklist of things you think are important. I find when I use them, I start weighting all the factors the same. I might pick the program with better housing, anatomy course, pediatrics rotation, conference reimbursement and call schedule over the one with a more academic and congenial atmosphere because they have 5 boxes checked off instead of 2 on my list. I think that your conscious mind is not always great keeping track of all of the various factors and their individual significances.

It's like how there isn't a well respected national PM&R residency program ranking (besides on sdn of course ). The ones we have are based on NIH funding or institution reputation because doing a real study using pros/cons lists in a computer would require quantifying and weighting all the possible factors. Computers wouldn't do as good a job of deciding where you should go than your personal impression.

I will concede that I may not be as fellowship focused as other applicants or perhaps as I should be. I think since I am less interested in interventional pain or sports, I may not take into account how competitive they are to get. However it does seem that as a medical student all your focus is on residency but as a resident all your focus is on fellowship. Maybe we should spend a little more time considering fellowships but not as much as a PGY3. Does that sound fair?

 

[MedBronc23]

Fair with the exception that I think some people are good at pros and cons lists.

I definitely had to make one for my final rank list. It actually helped solidify that the gut feeling I had about my number one was legit and that I Iiked some lesser known programs better than some big name places.

Just happy I landed at a big name with the training I wanted and a good personal fit for me and my family.

I think if most people search their heart they can end up at the right place. Somewhere that they like likes them provides good PMR base and opportunities for fellowship and/or job placement.

 

[Gauss]

look at the grads and where they go for fellowship and practice. Look back 10 years.
If you're weighing "better housing, anatomy course, pediatrics rotation, conference reimbursement" you're spinning your wheels

 

[Spartyon]

look at the grads and where they go for fellowship and practice. Look back 10 years.
If you're weighing "better housing, anatomy course, pediatrics rotation, conference reimbursement" you're spinning your wheels

Very true..if they are ending up where u think u may want to go i.e. Fellowship type, practice setting, staying on staff, etc. It gives a good idea of where the emphasis lies.