No idea where to do residency... help.

[GoodDoggy]

I'm feeling completely lost and looking for some honest advice from those who have been through this process. I am a competitive applicant who was lucky enough to interview all over the country at some great places. I really thought that I would finish this process and have a totally set rank list, but instead I am feeling lost.

My end goal: I will most likely (90%?) end up working in the community. I see myself also using my medical skills for things like DMAT, tactical medicine, etc, but I probably will not end up climbing the academic ladder at a university hospital.

Where I am stuck: I interviewed at some straight community shops that were in nice areas and left being convinced that if I am going into community medicine that this would be a great place to train. They convinced me that their grads are sought after because they know how to thrive in a community setting from start instead of the county people who need to learn it. My big questions were if I would see enough really sick patients and some of the more obscure things. I also interviewed at some of the big 4 year crazy county places. I don't NEED the county hospital madness, but if I will come out on the other end a much more competent physician then that is worth it in my end. I guess at the end of residency I want to start my career feeling like I am the most prepared I could possibly be. So far I ask everyone and the only answer I get is something along the lines of, "Every residency will prepare you for a community job."

In short, I'm stuck between ranking some solid 3 years higher than the "badass" 4 years because I have a fear that I am shorting myself and will be less competent in the future if I make that choice.

If anyone has advice I would really appreciate it. Thanks.

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[RustedFox]

3 year program for the win.

Tactical medicine? ... Stahhhpp.

 

[dadaddadaBATMAN]

I'm feeling completely lost and looking for some honest advice from those who have been through this process. I am a competitive applicant who was lucky enough to interview all over the country at some great places. I really thought that I would finish this process and have a totally set rank list, but instead I am feeling lost.

My end goal: I will most likely (90%?) end up working in the community. I see myself also using my medical skills for things like DMAT, tactical medicine, etc, but I probably will not end up climbing the academic ladder at a university hospital.

Where I am stuck: I interviewed at some straight community shops that were in nice areas and left being convinced that if I am going into community medicine that this would be a great place to train. They convinced me that their grads are sought after because they know how to thrive in a community setting from start instead of the county people who need to learn it. My big questions were if I would see enough really sick patients and some of the more obscure things. I also interviewed at some of the big 4 year crazy county places. I don't NEED the county hospital madness, but if I will come out on the other end a much more competent physician then that is worth it in my end. I guess at the end of residency I want to start my career feeling like I am the most prepared I could possibly be. So far I ask everyone and the only answer I get is something along the lines of, "Every residency will prepare you for a community job."

In short, I'm stuck between ranking some solid 3 years higher than the "badass" 4 years because I have a fear that I am shorting myself and will be less competent in the future if I make that choice.

If anyone has advice I would really appreciate it. Thanks.

Would strongly advise three year program if you have no compelling reason for a four year program. Huge investment in terms of money and more importantly time.

 

[dchristismi]

Three is seriously enough. You can never see it all... I’ve been an attending for 10 years (and damn do I feel old...) and I still see new stuff on a weekly basis. Like the lunate dislocation the other day.

And you do keep learning - it’s not as if medicine isn’t going to change... it absolutely does, and you’ll be continuing to learn oh, pretty much the rest of your career.

Some say that doing a 4th year is the $200,000 mistake. That’s for you to decide. (Yes, you can moonlight, but unless you’re really committed to a subspecialty, academics, or already have a PhD and just love school, the costs probably outweigh the benefits.)

 

[GoodDoggy]

3 year program for the win.

Tactical medicine? ... Stahhhpp.

Ha. I grew up in a police family and really just want someone to pay my range fee

 

[GoodDoggy]

Three is seriously enough. You can never see it all... I’ve been an attending for 10 years (and damn do I feel old...) and I still see new stuff on a weekly basis. Like the lunate dislocation the other day.

And you do keep learning - it’s not as if medicine isn’t going to change... it absolutely does, and you’ll be continuing to learn oh, pretty much the rest of your career.

Some say that doing a 4th year is the $200,000 mistake. That’s for you to decide. (Yes, you can moonlight, but unless you’re really committed to a subspecialty, academics, or already have a PhD and just love school, the costs probably outweigh the benefits.)

Really appreciate the opinion. Thanks for the reply.

 

[BoardingDoc]

Ha. I grew up in a police family and really just want someone to pay my range fee

You will make enough money to afford your own range fee. Moreover, you said you want to work in the community? Noone in the community will ever care that you did a tactical medicine fellowship, except maybe to make fun of you for it.

 

[GoodDoggy]

You will make enough money to afford your own range fee. Moreover, you said you want to work in the community? Noone in the community will ever care that you did a tactical medicine fellowship, except maybe to make fun of you for it.

Alright everyone forget I even mentioned this haha. I know numerous EM docs that run with the local SWAT teams. Some went to SWAT school and actually participate with the teams, others just help with medical training and can sit further back on calls if they even choose to participate that much. I'm not actually interested in a tactical medicine fellowship, but instead was throwing that out to demonstrate an example for work "extracurriculars".

 

[witzelsucht]

this seems like a no brainer. 3 year program +/- EMS/tactical fellowship. you wanna get good at bread and butter. no one graduates not knowing how to run a resus, you want to train like you fight so to speak

 

[Apollyon]

Like the lunate dislocation the other day.

The "spilled teacup"?? I knew it - you were just waiting for it!

 

[TooMuchResearch]

Three is seriously enough. You can never see it all... I’ve been an attending for 10 years (and damn do I feel old...) and I still see new stuff on a weekly basis. Like the lunate dislocation the other day.

And you do keep learning - it’s not as if medicine isn’t going to change... it absolutely does, and you’ll be continuing to learn oh, pretty much the rest of your career.

Some say that doing a 4th year is the $200,000 mistake. That’s for you to decide. (Yes, you can moonlight, but unless you’re really committed to a subspecialty, academics, or already have a PhD and just love school, the costs probably outweigh the benefits.)

But lunate dislocation is on every test and every review book, so we must see them everyday, right?!?

 

[shoal007]

I agree with the above posters. 3 years is long enough to get practice patterns, consults and how to figure out things that you don't know down. I've been an attending for 3 years and I'm still learning. I don't think the 4th year is going to make you any more prepared or a better doctor. As for location, in my shop, we have docs trained from county and community style shops. In general the community based program trained docs spend more time with patients and seem to start with higher PG scores. While the county docs seem to be slightly better or perhaps more cavalier with procedures.

IMHO, I don't think you can go wrong with your pick. Gl

Sent from my Pixel 2 using Tapatalk

 

[namethatsmell]

To add to the chorus: go to a 3 year program unless you need to be at a specific 4 year program (geography, etc).

And unless you plan to devote as much of your career as possible to swat/etc...don't waste your time (and cash) with that fellowship.

 

[engineeredout]

But lunate dislocation is on every test and every review book, so we must see them everyday, right?!?

Along with the high altitude cerebral edema, ciguatera, and monteggia fractures

 

[TheComebacKid]

I'll be the odd man out and throw out a different perspective that you don't see on SDN much... I think 4 year programs have A LOT of significant advantages. I currently go to a 4 year program and if I had to do it all over again I would in a heartbeat.

The biggest thing that 4 year programs offer is flexibility. If you definitely want to go into academics you should give 4 year programs higher consideration. But if you aren't sure if community might be for you, you can still go into the community coming from a 4 year program. Want to do a fellowship? 4 year programs will optimally position you for that too. All avenues are open coming from a 4 year shop.

While going to a 3 year program does not close doors for you, i.e. you can still do academics/fellowship etc, by and large I think you are at a disadvantage. At my 4 year program, all new attendings that are hired need to be from a 4 year program. They do not want to hire someone new from a 3 year program to supervise residents who essentially has the same degree of training as our PGY-4s. If you are going to go for a "competitive" job after residency I think having 4 years makes a difference. Want to work in LA at one of the big county hospitals? You should preferably come from a 4 year program because all those programs are 4 years there. But in terms of your regular community group, they likely will not care.

If you are in any way interested in Disaster Medicine, prehospital care, tactical EMS and so forth, I would recommend a 4 year program to get adequate exposure. Our program has a robust EMS fellowship with faculty that are invested in this stuff, and we work SWAT and law enforcement regularly if we are interested (as residents). Some three year programs (especially community ones) usually don't have the infrastructure to support that kind of involvement during residency (however others definitely do, it depends on the program). Furthermore, in a 4 year program you work less shifts/month allowing you opportunity to explore other interests. 3 year programs are more heavily stacked with clinical shifts. If you think this is just an "interest" of yours that you would like to flirt around with as a hobby, you may not need 4 years and/or fellowship, but if you want to make it a part of your career, you should consider 4 years.

Do I think we get "better" clinical training in a 4 year program? No. I think from a purely clinical emergency medicine standpoint the people who come out of 3 year programs are just as good as those who come out of 4 year programs. But I do think we are fortunate to have many opportunities for other interests in EM. If you know you are going to be a community ED doc and clock in/clock out (ain't nothing wrong with that btw) it's probably overkill. Also, the financial loss to doing any extra year is not trivial. Definitely a huge selling point for a 3 year program.

I don't want to give you the impression that if you go into a 3 year program you are locked into a community job, can't do academics/fellowship etc. That is completely false. But I do think 4 year programs offer more long term options.

 

[CajunMedic]

I see myself also using my medical skills for things like DMAT, tactical medicine, etc,

Just a heads up. If you are interested in DMAT, be prepared to wait. Hiring process can take up to a year, that's once they list an opening. I've been on one since before med school and will be stuck as a GS-7 Logistics Coordinator until at least my second year of residency, then as long as it takes to get me hired into the physician slot.

 

[deleted547339]

I'll be the odd man out and throw out a different perspective that you don't see on SDN much... I think 4 year programs have A LOT of significant advantages. I currently go to a 4 year program and if I had to do it all over again I would in a heartbeat.

The biggest thing that 4 year programs offer is flexibility. If you definitely want to go into academics you should give 4 year programs higher consideration. But if you aren't sure if community might be for you, you can still go into the community coming from a 4 year program. Want to do a fellowship? 4 year programs will optimally position you for that too. All avenues are open coming from a 4 year shop.

While going to a 3 year program does not close doors for you, i.e. you can still do academics/fellowship etc, by and large I think you are at a disadvantage. At my 4 year program, all new attendings that are hired need to be from a 4 year program. They do not want to hire someone new from a 3 year program to supervise residents who essentially has the same degree of training as our PGY-4s. If you are going to go for a "competitive" job after residency I think having 4 years makes a difference. Want to work in LA at one of the big county hospitals? You should preferably come from a 4 year program because all those programs are 4 years there. But in terms of your regular community group, they likely will not care.

If you are in any way interested in Disaster Medicine, prehospital care, tactical EMS and so forth, I would recommend a 4 year program to get adequate exposure. Our program has a robust EMS fellowship with faculty that are invested in this stuff, and we work SWAT and law enforcement regularly if we are interested (as residents). Some three year programs (especially community ones) usually don't have the infrastructure to support that kind of involvement during residency (however others definitely do, it depends on the program). Furthermore, in a 4 year program you work less shifts/month allowing you opportunity to explore other interests. 3 year programs are more heavily stacked with clinical shifts. If you think this is just an "interest" of yours that you would like to flirt around with as a hobby, you may not need 4 years and/or fellowship, but if you want to make it a part of your career, you should consider 4 years.

Do I think we get "better" clinical training in a 4 year program? No. I think from a purely clinical emergency medicine standpoint the people who come out of 3 year programs are just as good as those who come out of 4 year programs. But I do think we are fortunate to have many opportunities for other interests in EM. If you know you are going to be a community ED doc and clock in/clock out (ain't nothing wrong with that btw) it's probably overkill. Also, the financial loss to doing any extra year is not trivial. Definitely a huge selling point for a 3 year program.

I don't want to give you the impression that if you go into a 3 year program you are locked into a community job, can't do academics/fellowship etc. That is completely false. But I do think 4 year programs offer more long term options.

I think you’re entirely off based. If you want to be a purely clinical academician immediately following training and have no desire to anything else, ever, then a 4 year program is superior. In all other aspect (excluding family/location considerations), a 3 year program is far superior. Who do you think a 4 year program would rather hire? A new 4 year grad, or a 3 year grad with fellowship training in ultrasound, education, sim, admin, ems, whatever - or a 3 year grad who went out and spent time actually walking the walk in the community. And besides, if you want to do ems or US or any other niche that already has an existing formal fellowship pathway in a 4 year training program, do you think they’re going to say “well, he did a 4 year program, so he’s probably legit.” Further, after 1 year of being an attending, you’re the same “age” - you could do a 3 year program, then spend a year on faculty at your home program.

Sorry to be confrontational, but I think you drank the koolaid.

 

[surfdoc29]

Furthermore, in a 4 year program you work less shifts/month allowing you opportunity to explore other interests. 3 year programs are more heavily stacked with clinical shifts.

Just want to say for OPs sake (and I'm fairly sure they are already aware of this but I digress) that this statement is totally incorrect. Most 4 year programs actually work just as many, if not more, shifts/month, you just get more elective blocks to make up for it. Think about like USC, Denver, etc. working 20+ shifts/month. Having just wrapped up the interview trail I can tell you that there really isn't a difference in shift load during EM blocks between 3 and 4 year programs. The main difference you'll find is amount of elective blocks which do allow you to decompress your schedule a bit, but you have to ask yourself if doing an extra year of residency for 3-4 extra months of elective time (spread over 4 years) is worth it. For some people it is, but that's a personal preference.

 

[Gray Fox]

Just want to say for OPs sake (and I'm fairly sure they are already aware of this but I digress) that this statement is totally incorrect. Most 4 year programs actually work just as many, if not more, shifts/month, you just get more elective blocks to make up for it. Think about like USC, Denver, etc. working 20+ shifts/month. Having just wrapped up the interview trail I can tell you that there really isn't a difference in shift load during EM blocks between 3 and 4 year programs. The main difference you'll find is amount of elective blocks which do allow you to decompress your schedule a bit, but you have to ask yourself if doing an extra year of residency for 3-4 extra months of elective time (spread over 4 years) is worth it. For some people it is, but that's a personal preference.

Also finished up the interview trail, and I'd disagree. Even the busy 4 year county programs were incorporating more elective months, which obviously decrease shifts/month during that time. For academic programs, some offered up to 4-5 months of elective time and seemed much better about decreasing shift #s with seniority.

Even PGY-3s of well known 3 year programs were saying PGY-4s of 4 year programs were better clinically because they get a whole year of extra training (total aggregate clinical hours), so community/academic/county programs will recruit a PGY-4 over a PGY-3 (fresh out of residency). Well known EM docs I've spoken to who've trained at many different practice settings have consistently said the same thing: EM should be 3.5 years of training. 3 years is too short, 4 years is too long, pick your poison.

If I were dead set on going community full time for the rest of my life, I'd pick 3 years. If you're not sure, prefer more time for structured learning, want a niche, etc., no one should give you flak for seriously considering 4 years.

I'm seriously considering 4 years, but this is heavily influenced by QOL, family, geographic preference, memories I want to make, and opportunity to moonlight. I also don't need the county craziness, but I might go county, who knows. It's not always about the $$$.

 

[GonnaBeADoc2222]

Having recently graduated from a 4 year program, my opinion is...go to a 3 year program. There are plenty of academically strong 3 year programs that can funnel you into academics if you so choose. Yes, there are some 4 year programs that will take only 4 year graduates, so what? If going into academics, a great option would be a 3 year program followed by fellowship.

Yes, the shift structure can be more relaxed and yes there is more elective time, yada yada. Who cares? I would have liked to make 300k more and forego an extra month of ultrasound - no amount of moonlighting will make up for this lost income.

A garbage clinician after 3 years of training isn't all of a sudden going to magically become a rock star during PGY-4 year.

4 year programs are great for hospitals who want to reduce midlevel coverage in their EDs, and thus save on payroll. Money is certainly not everything, but it got to me during my PGY4 year seeing midlevels straight out of PA school make 1.5x my salary and having 0.25x my skills and speed.

Also, don't underestimate the importance of proximity to family/friends during residency. Although EM is a relatively easier residency than what I saw my friends go though in other fields, it's still a trying time.

 

[deleted547339]

A garbage clinician after 3 years of training isn't all of a sudden going to magically become a rock star during PGY-4 year.

So true.

 

[surfdoc29]

Also finished up the interview trail, and I'd disagree. Even the busy 4 year county programs were incorporating more elective months, which obviously decrease shifts/month during that time. For academic programs, some offered up to 4-5 months of elective time and seemed much better about decreasing shift #s with seniority.

Even PGY-3s of well known 3 year programs were saying PGY-4s of 4 year programs were better clinically because they get a whole year of extra training (total aggregate clinical hours), so community/academic/county programs will recruit a PGY-4 over a PGY-3 (fresh out of residency). Well known EM docs I've spoken to who've trained at many different practice settings have consistently said the same thing: EM should be 3.5 years of training. 3 years is too short, 4 years is too long, pick your poison.

If I were dead set on going community full time for the rest of my life, I'd pick 3 years. If you're not sure, prefer more time for structured learning, want a niche, etc., no one should give you flak for seriously considering 4 years.

I'm seriously considering 4 years, but this is heavily influenced by QOL, family, geographic preference, memories I want to make, and opportunity to moonlight. I also don't need the county craziness, but I might go county, who knows. It's not always about the $$$.

I think you misunderstood what I said... I said that during EM months shifts aren't reduced in a 4-year compared to 3-year. Yes you will have more elective time, most 4 year programs have anywhere from 4-6 months from what I've seen as compared to like 2 for 3 years. So yes, you'll have less clinical shifts during your elective months, but do you really want to do another year of residency for 2-4 months of extra elective time? Doesn't seem like a great trade off to me.

Also, I have to disagree with the part of your statement regarding residents from 4-year programs getting preferentially hired. I haven't heard that anywhere with the exception of the 4-year programs who won't hire 3-year grads straight out of residency. IMO it'd be better to do a 3-year+fellowship or even work in the community for year and then go work there (less opportunity cost, more opportunity to develop a niche via fellowship.

I'm not hating on 4-years, I will have some fairly high up on my rank list due to location/family reasons, but I think using the reason of more elective time or less shifts as a reason to go to a 4-year is silly, as is the myth of preferential hiring for 4-year grads.

 

[Gray Fox]

I think you misunderstood what I said... I said that during EM months shifts aren't reduced in a 4-year compared to 3-year. Yes you will have more elective time, most 4 year programs have anywhere from 4-6 months from what I've seen as compared to like 2 for 3 years. So yes, you'll have less clinical shifts during your elective months, but do you really want to do another year of residency for 2-4 months of extra elective time? Doesn't seem like a great trade off to me.

Also, I have to disagree with the part of your statement regarding residents from 4-year programs getting preferentially hired. I haven't heard that anywhere with the exception of the 4-year programs who won't hire 3-year grads straight out of residency. IMO it'd be better to do a 3-year+fellowship or even work in the community for year and then go work there (less opportunity cost, more opportunity to develop a niche via fellowship.

I'm not hating on 4-years, I will have some fairly high up on my rank list due to location/family reasons, but I think using the reason of more elective time or less shifts as a reason to go to a 4-year is silly, as is the myth of preferential hiring for 4-year grads.

The 4 year programs I interviewed at had decreasing # shifts with seniority during their EM months, so I didn't misunderstand you. You ALSO have less shifts during your elective months.

I've spoken to over a dozen community and academic EM docs (who hire) about the preferential hiring. Straight out of residency, there are popular shops that prefer the 4 year resident over the 3 year resident. Again, emphasis on straight out of residency. If you think it's a myth, you do you bro.

Your argument about opportunity cost is valid for some, invalid for others. Some people genuinely want to be thought leaders in EM and derive greater satisfaction from research innovation and impact in the field over financial gain. It is what it is.

 

[Gray Fox]

So true.

I'd imagine a garbage clinician after 3 years will be less of a garbage clinician after 4 years. That's the hope anyways.

I'd rather have the less garbage clinician after 4 years practice independently without supervision.

I'm not disagreeing though. I've worked with rockstar docs from 3 year EM programs. I'm just saying it might not be for everyone.

 

[surfdoc29]

The 4 year programs I interviewed at had decreasing # shifts with seniority during their EM months, so I didn't misunderstand you. You ALSO have less shifts during your elective months.

I've spoken to over a dozen community and academic EM docs (who hire) about the preferential hiring. Straight out of residency, there are popular shops that prefer the 4 year resident over the 3 year resident. Again, emphasis on straight out of residency. If you think it's a myth, you do you bro.

Your argument about opportunity cost is valid for some, invalid for others. Some people genuinely want to be thought leaders in EM and derive greater satisfaction from research innovation and impact in the field over financial gain. It is what it is.

Every 3 year program I've interviewed at also has decreasing # of shifts with seniority, but that's not what I'm referring to, so you did misunderstand me. What I'm saying is that during EM months during the same year there is no difference between # of shifts per month between 3 and 4 year programs, i.e. LAC doing 20 12s intern year, Harbor doing 20 8s, Denver doing 22 8s, etc vs Vanderbilt doing 19 10s, MUSC doing 20 8s, Carolinas doing 20 10s, etc. Similar shift loads on EM months and # of shifts decrease every year.

I have also talked to tons of docs in different aspects of the field, and the vast, vast majority of them say they don't really care whether you did a 3 or 4 year residency as long as you're competent and fit in with personalities, which is way more important for EM groups when they hire. Additionally, as far as where you train, yes if you want to work at a county place, it might be better to train at a county site, but 3 vs 4 year really doesn't matter (in fact, not a single doc I've talked to has cared about this).

Saying you can't be a leader in the field coming from a 3-year residency is absurd. Some of the top EM programs are 3-year programs, even in academics.

Again, I'm not hating on 4-year programs, there are a lot of great 4-year programs and some people have some great reasons for going to them (like I said, there will be some fairly high on my own list), but I just want to stop the perpetuation of the notion that somehow if you go to a 4-year you're gonna work less every month outside of a couple extra months of elective time and that you can't be a leader in the field if you go to a 3-year program or work in academics or a county shop.

 

[Gray Fox]

Every 3 year program I've interviewed at also has decreasing # of shifts with seniority, but that's not what I'm referring to, so you did misunderstand me. What I'm saying is that during EM months during the same year there is no difference between # of shifts per month between 3 and 4 year programs, i.e. LAC doing 20 12s intern year, Harbor doing 20 8s, Denver doing 22 8s, etc vs Vanderbilt doing 19 10s, MUSC doing 20 8s, Carolinas doing 20 10s, etc. Similar shift loads on EM months and # of shifts decrease every year.

I have also talked to tons of docs in different aspects of the field, and the vast, vast majority of them say they don't really care whether you did a 3 or 4 year residency as long as you're competent and fit in with personalities, which is way more important for EM groups when they hire. Additionally, as far as where you train, yes if you want to work at a county place, it might be better to train at a county site, but 3 vs 4 year really doesn't matter (in fact, not a single doc I've talked to has cared about this).

Saying you can't be a leader in the field coming from a 3-year residency is absurd. Some of the top EM programs are 3-year programs, even in academics.

Again, I'm not hating on 4-year programs, there are a lot of great 4-year programs and some people have some great reasons for going to them (like I said, there will be some fairly high on my own list), but I just want to stop the perpetuation of the notion that somehow if you go to a 4-year you're gonna work less every month outside of a couple extra months of elective time and that you can't be a leader in the field if you go to a 3-year program or work in academics or a county shop.

I admit i misunderstood your first point then.

You've talked to a lot of docs, I've talked to a lot of docs, doesn't discount my conversations. Based on your talks, seems like shops don't care as an absolute rule. Based on mine, some shops value 4 year programs a lot more. Our conclusions aren't necessarily mutually exclusive and they might reflect the geographic region in which we asked.

You're putting words in my mouth and beating on a straw man. I never said you can't be a leader in the field in a 3 year program or work in county or academics.

If you think, on average, the research/innovation output by residents in 3 vs 4 year and even by 3 vs 4 year institutions is equal, you are sadly, sadly mistaken.

I have no doubt you will be competent in a 3 or 4 yr program, so why don't we agree to disagree.

 

[SpacemanSpifff]

I'm feeling completely lost and looking for some honest advice from those who have been through this process. I am a competitive applicant who was lucky enough to interview all over the country at some great places. I really thought that I would finish this process and have a totally set rank list, but instead I am feeling lost.

My end goal: I will most likely (90%?) end up working in the community. I see myself also using my medical skills for things like DMAT, tactical medicine, etc, but I probably will not end up climbing the academic ladder at a university hospital.

Where I am stuck: I interviewed at some straight community shops that were in nice areas and left being convinced that if I am going into community medicine that this would be a great place to train. They convinced me that their grads are sought after because they know how to thrive in a community setting from start instead of the county people who need to learn it. My big questions were if I would see enough really sick patients and some of the more obscure things. I also interviewed at some of the big 4 year crazy county places. I don't NEED the county hospital madness, but if I will come out on the other end a much more competent physician then that is worth it in my end. I guess at the end of residency I want to start my career feeling like I am the most prepared I could possibly be. So far I ask everyone and the only answer I get is something along the lines of, "Every residency will prepare you for a community job."

In short, I'm stuck between ranking some solid 3 years higher than the "badass" 4 years because I have a fear that I am shorting myself and will be less competent in the future if I make that choice.

If anyone has advice I would really appreciate it. Thanks.

Choose the place you feel most at home and the place that will set you up for your future goals. As stated above, if you want to be a community doc, you'll be well trained at many, many programs - regardless of the length. The biggest factor in your future competency as an EM doc is your effort during residency. Sounds like you care, therefore, you'll put in the effort to take advantage of your training regardless of your ultimate destination. Be comfortable knowing that you're choosing between a number of excellent options, all of which can get you where you want to go.

As for 3 vs. 4, I always thought it was a weird debate. As previously mentioned, the opportunity cost of a year of training means a lot to some folks, less to others. I judged programs based off how I felt when I visited and what they could offer me. I ended up at a 4 because I liked it the best - plus it had a few opportunities that I thought would make me uniquely prepared to pursue my career interests. I work more than any of my friends who are interns at other EM programs (both 3 and 4). I don't anticipate having any difficulty landing a job after graduation, not because I'm coming from a 4 year program, but because I'm coming from a damn good one. Grads from damn good 3 year programs (there are many) probably have similar expectations, and rightly so.

 

[DrYoda]

Personally the first thing I narrowed down while applying was eliminating all 4 year programs, but that's just me. As for community vs. academic, I can't say I trained at a true academic center but did train at a big county-style tertiary care center with residents in most specialties present. All of my residency class minus one who did a fellowship went into community practice without any issues. At the time my community shop was actually looking for people with my particular training background due to some of the hospital's goals at the time, so probably just depends.

 

[Dr.CCM]

Do a three year program unless for other reasons like location or you just like the place better the 4 years won’t matter.

The idea that EM should be 3.5 years doesn’t make that much sense to me. It’s all about patient exposure and plenty of the three year programs that graduate residents will have more than enough patient exposure at their shop in 2.5 years let alone 3. You don’t need 4.

Plus if you want to be a true leader in our field, you need to make roads in some kind of niche sub specialty or otherwise. So if that 4 year program gives you the resources, that’s great.

I’m doing CC fellowship now and can’t imagine jumping into it after a 4 year program, I would’ve needed a break and may not have even gone back to it.

 

[deleted547339]

I admit i misunderstood your first point then.

You've talked to a lot of docs, I've talked to a lot of docs, doesn't discount my conversations. Based on your talks, seems like shops don't care as an absolute rule. Based on mine, some shops value 4 year programs a lot more. Our conclusions aren't necessarily mutually exclusive and they might reflect the geographic region in which we asked.

You're putting words in my mouth and beating on a straw man. I never said you can't be a leader in the field in a 3 year program or work in county or academics.

If you think, on average, the research/innovation output by residents in 3 vs 4 year and even by 3 vs 4 year institutions is equal, you are sadly, sadly mistaken.

I have no doubt you will be competent in a 3 or 4 yr program, so why don't we agree to disagree.

Do a three year program unless for other reasons like location or you just like the place better the 4 years won’t matter.

The idea that EM should be 3.5 years doesn’t make that much sense to me. It’s all about patient exposure and plenty of the three year programs that graduate residents will have more than enough patient exposure at their shop in 2.5 years let alone 3. You don’t need 4.

Plus if you want to be a true leader in our field, you need to make roads in some kind of niche sub specialty or otherwise. So if that 4 year program gives you the resources, that’s great.

I’m doing CC fellowship now and can’t imagine jumping into it after a 4 year program, I would’ve needed a break and may not have even gone back to it.

That would seem soul crushing....

 

[MSmentor018]

you know what's really sought after...an EM boarded doc with a blood pressure. I've never heard of anyone not getting a job b/c they went to X so don't worry

Now that the ED is more of a convenient clinic, primary care center, part observation hotel I think a 3.5 yr program would be ideal but it doesn't exist so 3 or 4yr. is purely a personal choice. There are a few rotations I wished I had but doesn't exist for us like hand surgery, endocrine, ent but I can get that knowledge from just reading and asking

if you're considering fellowship, that maybe where you want to do residency. there's a much higher chance of choosing someone from the program than not. unless of course you didn't do well then your chance there is shot.

don't worry about taking care of pts and such. no matter where you train the core "milestones" are all the same. you're going to get X # months of icu, peds...etc and you'll be well trained when you get out. you're not going to know it all. i try to read/podcast/FB emdocs!/videos/chart review at least 1 hr a day or look stuff up

I use to do swat but now just stick with dmat, hospital disaster stuff, ultrasound. all are cool but can be time consuming. with increasing pressures and all the stuff you're reading about working in the ED, you may not feel it now but burnout is a real concern. I like my off time away from clinical medicine plus as i get older I have a lot more to lose than 20 yrs ago. so I pick and choose the risk.

I work part time community, a day or two in academics just to work with the residents. you can do anything you want without being in academics whether swat, wilderness, ems, sports med, pain....etc. but yes, most jobs are in the community.

 

[Situasian]

I currently am training in a medium sized community hospital with periodic shifts at our mothership level 1. I can honestly say I see sicker patients in the community hospital. On top of that, being in a small hospital you will learn to manage everything yourself and become good at it. There are no stroke teams, trauma teams, ortho APPs, or other residents and fellows. You TPA your own patients, run your own traumas, reduce your own fractures, place your own lines, and chest tubes. If someone needs a TV pacer you place it. Cardiology may not be there. At a level 1 center you may see more, but rarely do you get to actively get your hands dirty. I think the benefit of a level 1 is that it teaches you to handle more volume and speed up your disposition. I would go with a community 3 year program.

 

[namethatsmell]

Just go to In-N-Out and be done with it.

The length of training, acuity, and work load is perfect.

And yes, your bench press PR is guaranteed to go up 50lbs by the time you're done.

 

[SpacemanSpifff]

I currently am training in a medium sized community hospital with periodic shifts at our mothership level 1. I can honestly say I see sicker patients in the community hospital. On top of that, being in a small hospital you will learn to manage everything yourself and become good at it. There are no stroke teams, trauma teams, ortho APPs, or other residents and fellows. You TPA your own patients, run your own traumas, reduce your own fractures, place your own lines, and chest tubes. If someone needs a TV pacer you place it. Cardiology may not be there. At a level 1 center you may see more, but rarely do you get to actively get your hands dirty. I think the benefit of a level 1 is that it teaches you to handle more volume and speed up your disposition. I would go with a community 3 year program.

Definitely depends on the program. We are not all created equal. If you are primarily at a community program, and rotate as a guest at your local level 1, why would they let you run the show? But when your program's home base is the level 1, and you own the department, you own all the procedures that come with it - intubations, chest tubes, trialysis catheters, yes, even TV pacers. All those go to the residents. We TPA our own patients. We even reduce our own distal radius fractures...

 

[GonnaBeADoc2222]

At a level 1 center you may see more, but rarely do you get to actively get your hands dirty.

That's a pretty sweeping generalization. I trained at a 4 year highly academic level 1 center and got my hands plenty dirty. Plenty of intubations, lines, chest tubes, trauma resus, peds exposure. Placed a couple TV pacers. Also came out very well trained to deal with volume. I do feel substantially weaker in ortho however, as we had an active ortho residency.

I enjoyed my time at my program. I liked the people, the location and the relative proximity to my family.

I still say go to 3 year program. The concept of a 3.5 year program seems ridiculous to me. There is a reason why 85% of ACGME / RRC approved programs are 3 year programs: because it's an adequate amount of clinical training.

Very few reasons to go to a 4 year program:
1) If you value proximity to family / friends very highly and there are no 3 year programs around.
2) You know you want to be an academic, and, prior to residency, you've already established a niche and a strong research relationship with a faculty member who is at a 4 year program that you think continuing to work closely with will further your academic career.

Academic niche in EM these days is created by doing a fellowship. Don't be fooled by the concept of these PGY4 years masquerading as "mini-fellowships."

"Fit" is an important concept, but one that I think is overvalued by candidates, or at least, they overestimate their ability to accurately perceive it. Unless you spent a month on an audition rotation with a given program, your perceived "fit" with them is based on a 2-3 hour pre-interview dinner (if you even go) during which a random sample of residents will be in attendance (based on who is off / feels like trekking out on a given night - btw, fyi, the residents who are picked by leadership to organize these events and, thus, are the most likely ones to be in attendance, are frequently program "cheerleaders" and will likely give you an overall positively biased view) and a 4-5 hour interview day where everyone and everything will be presented to you at its shiniest best. For this reason, I do think that flat out negative feelings about a program after this experience are likely a red flag and a feeling you should trust. However, don't go crazy trying to separate out just how "good" you felt about multiple programs simply on the basis of "fit."

You will get the same clinical training everywhere, believe me.

 

[swamprat]

I am a graduate of a 3 year and I honestly felt ready in 2.5. It was an intense 3 years but nonetheless glad I did a 3 year. While my med school classmates are still residents, I am in fellowship, moonlighting at a level 1 trauma center, passed my written boards and overall way happier than when I was a resident. Hands down would never even consider a 4 year program. I did interview at a bunch but at the end of the day I ranked them lower because none of them really gave me a good reason for the extra year. And from the attendings at my former program that graduated from 4 year programs, not one of them thought that extra year was worth it.

 

[TheComebacKid]

I think you’re entirely off based. If you want to be a purely clinical academician immediately following training and have no desire to anything else, ever, then a 4 year program is superior. In all other aspect (excluding family/location considerations), a 3 year program is far superior. Who do you think a 4 year program would rather hire? A new 4 year grad, or a 3 year grad with fellowship training in ultrasound, education, sim, admin, ems, whatever - or a 3 year grad who went out and spent time actually walking the walk in the community. And besides, if you want to do ems or US or any other niche that already has an existing formal fellowship pathway in a 4 year training program, do you think they’re going to say “well, he did a 4 year program, so he’s probably legit.” Further, after 1 year of being an attending, you’re the same “age” - you could do a 3 year program, then spend a year on faculty at your home program.

Sorry to be confrontational, but I think you drank the koolaid.

Not exactly sure why my post got you all hot and bothered. Regardless, I stick to my point. There's no koolaid. In fact, I think the vast majority of people prefer going to 3 year programs and the consensus is that it's hard to justify a 4th year. I think I'm the only one on here is didn't drink the koolaid.

I'm in a 4 year program and I can tell you without a doubt that I made the correct choice for myself. I know the financial implications of doing an extra year are a big deal, but otherwise, whether I chose a community job or an academic job I feel confident I have all my doors open.

I think 4 years + no fellowship gets you hired at a good number of academic places if that's what you want to do (and obviously the same community gigs as 3 year programs).

3 years + no fellowship makes it much more competitive to get a job in academics, unless you are trying to get hired a 3 year place. If you went to a 3 year program and do no fellowship I think it's very difficult to get hired at a 4 year program.

3 years + fellowship is not a bad combination and yes you can get hired at many academic places including 4 year places, but I can tell you that 4 year programs prefer to hire people who come from 4 year programs. You can look at the faculty at any 4 year program and you'll see the majority of them are coming from 4 year residencies (many who do 4 years + fellowship).

Nobody says that "4 year residents are more legit than 3 year residents". What I said is that if you are considering academics/fellowship/developing a niche, having a 4 year program with more elective time built in gives you an opportunity to decide if it's right for you. You can do a month of tox/ems/us, extra ICU rotations etc to figure out what you want to do. You make a more informed decision. In addition, not all 3 year programs (especially not community based ones) have extensive fellowships in house for your to check out. Maybe that's not worth it to you, but to some it is.

If you want to do community and you are 100% set on it, then you absolutely should consider 3 year programs higher. But if you aren't sure, are flirting with the idea of doing fellowship/academics, a 4 year program is a good option because no doors are closed for you.

Just want to say for OPs sake (and I'm fairly sure they are already aware of this but I digress) that this statement is totally incorrect. Most 4 year programs actually work just as many, if not more, shifts/month, you just get more elective blocks to make up for it. Think about like USC, Denver, etc. working 20+ shifts/month. Having just wrapped up the interview trail I can tell you that there really isn't a difference in shift load during EM blocks between 3 and 4 year programs. The main difference you'll find is amount of elective blocks which do allow you to decompress your schedule a bit, but you have to ask yourself if doing an extra year of residency for 3-4 extra months of elective time (spread over 4 years) is worth it. For some people it is, but that's a personal preference.

Having also gone on the interview trail and interviewing at 3 and 4 year programs, and now as a resident at a 4 year program, I can tell you that there is a shift difference. Our seniors are working anywhere from 14-18 shifts a month compared to seniors at some 3 year programs which are working 20+ shifts a month. Yes Denver and USC are the exception that offer a particularly brutal shift load, but many 4 year programs don't make you work that many shifts.

 

[Gray Fox]

Not exactly sure why my post got you all hot and bothered. Regardless, I stick to my point. There's no koolaid. In fact, I think the vast majority of people prefer going to 3 year programs and the consensus is that it's hard to justify a 4th year. I think I'm the only one on here is didn't drink the koolaid.

I'm in a 4 year program and I can tell you without a doubt that I made the correct choice for myself. I know the financial implications of doing an extra year are a big deal, but otherwise, whether I chose a community job or an academic job I feel confident I have all my doors open.

I think 4 years + no fellowship gets you hired at a good number of academic places if that's what you want to do (and obviously the same community gigs as 3 year programs).

3 years + no fellowship makes it much more competitive to get a job in academics, unless you are trying to get hired a 3 year place. If you went to a 3 year program and do no fellowship I think it's very difficult to get hired at a 4 year program.

3 years + fellowship is not a bad combination and yes you can get hired at many academic places including 4 year places, but I can tell you that 4 year programs prefer to hire people who come from 4 year programs. You can look at the faculty at any 4 year program and you'll see the majority of them are coming from 4 year residencies.

Nobody says that "4 year residents are more legit than 3 year residents". What I said is that if you are considering academics/fellowship/developing a niche, having a 4 year program with more elective time built in gives you an opportunity to decide if it's right for you. You can do a month of to/ems/us, extra ICU rotations etc to figure out what you want to do. You make a more informed decision. In addition, not all 3 year programs (especially not community based ones) have extensive fellowships in house for your to check out. Maybe that's not worth it to you, but to some it is.

If you want to do community and you are 100% set on it, then you absolutely should consider 3 year programs higher. But if you aren't sure, are flirting with the idea of doing fellowship/academics, a 4 year program is a good option because no doors are closed for you.



Having also gone on the interview trail and interviewing at 3 and 4 year programs, and now as a resident at a 4 year program, I can tell you that there is a shift difference. Our seniors are working anywhere from 14-18 shifts a month compared to seniors at some 3 year programs which are working 20+ shifts a month. Yes Denver and USC are the exception that offer a particularly brutal shift load, but many 4 year programs don't make you work that many shifts.

Love this response.
@surfdoc29 OK, nevermind, I didn't misunderstand you, and I was right! I remember on the interview trail, seniors in 4 year programs work less total shifts than 3 year programs (although shift #s decrease with seniority for both). I remember LAC and Denver were the exceptions, although LAC increased their spots to 18 this year.
Also, most of the 4th years at the places I interviewed went on to get a fellowship or get into a research scholars program to become niche leaders, so makes the 3+1 argument less compelling, but alas, I know that's sacrilege to many people on this thread (2 years of attending salary).
Thanks to all the contributors on this thread though--although I'm not OP, I'm going back to the drawing board to seriously reassess my rank list.

 

[BoardingDoc]

3 years + fellowship is not a bad combination and yes you can get hired at many academic places including 4 year places, but I can tell you that 4 year programs prefer to hire people who come from 4 year programs. You can look at the faculty at any 4 year program and you'll see the majority of them are coming from 4 year residencies.

The argument that 4 year programs hire a lot of people from 4 year programs is utterly meaningless as it is a statistical certainty. Of course 4 year programs hire more 4 year residency grads. Hiring from one's own residency is common everywhere. In the case of 4 year programs, this by definition means you get more 4 year trained docs. Moreover, there is a significantly higher number of 4 year grads out there than there are 3 year + fellowship grads out there. This also skews the numbers towards more 4 year grads working there than 3 year.

You might be right about 4 year programs actually preferring 4 year graduates over 3+fellowship graduates, I have no idea, I went to a 3 year program. That said, if you require 4 years of training to get a job and your pool consists of 80 4 year grads and 20 3 year+fellowship grads, the fact that a higher number of 4 year grads get hired shouldn't be surprising. What actually matters is what percentage is hired from each pool.

 

[surely]

"Fit" is an important concept, but one that I think is overvalued by candidates, or at least, they overestimate their ability to accurately perceive it. Unless you spent a month on an audition rotation with a given program, your perceived "fit" with them is based on a 2-3 hour pre-interview dinner (if you even go) during which a random sample of residents will be in attendance (based on who is off / feels like trekking out on a given night - btw, fyi, the residents who are picked by leadership to organize these events and, thus, are the most likely ones to be in attendance, are frequently program "cheerleaders" and will likely give you an overall positively biased view) and a 4-5 hour interview day where everyone and everything will be presented to you at its shiniest best. For this reason, I do think that flat out negative feelings about a program after this experience are likely a red flag and a feeling you should trust. However, don't go crazy trying to separate out just how "good" you felt about multiple programs simply on the basis of "fit."

You will get the same clinical training everywhere, believe me.

I needed to hear this. Thank you, seriously.

 

[surfdoc29]

Love this response.
@surfdoc29 OK, nevermind, I didn't misunderstand you, and I was right! I remember on the interview trail, seniors in 4 year programs work less total shifts than 3 year programs (although shift #s decrease with seniority for both). I remember LAC and Denver were the exceptions, although LAC increased their spots to 18 this year.
Also, most of the 4th years at the places I interviewed went on to get a fellowship or get into a research scholars program to become niche leaders, so makes the 3+1 argument less compelling, but alas, I know that's sacrilege to many people on this thread (2 years of attending salary).
Thanks to all the contributors on this thread though--although I'm not OP, I'm going back to the drawing board to seriously reassess my rank list.

I still have to disagree after going through my notes. The lowest # of shifts per month I saw was 16, which I saw at both 3 year and 4 year programs. The average was probably around 17, and there really is not a noticeable difference between the shift #s per month.

Having also gone on the interview trail and interviewing at 3 and 4 year programs, and now as a resident at a 4 year program, I can tell you that there is a shift difference. Our seniors are working anywhere from 14-18 shifts a month compared to seniors at some 3 year programs which are working 20+ shifts a month. Yes Denver and USC are the exception that offer a particularly brutal shift load, but many 4 year programs don't make you work that many shifts.

Please name me one 3 year program that has its 3rd year residents working 20+ shifts a month. Not a single one I interviewed at had more than 18.

 

[Apollyon]

lease name me one 3 year program that has its 3rd year residents working 20+ shifts a month. Not a single one I interviewed at had more than 18.

This was several/many years ago, but St. John's in Detroit had third years doing 20 12s. Also, I think Newark-BI was 20x12 for third years.

 

[littlejuan]

I went to a 3 year program and got plenty of offers from academic places, some very big names too. I have a buddy that was hired at a 4 year program right out of a 3 year program. He just didn’t work with 4th years his first year there. Not sure how common that is though.

 

[Dr.CCM]

If you want to do academics:

3 years + fellowship or just 3 years.

You want to be an expert in something, do the fellowship not a mini fellowship.

If you have other circumstances like location, resident vibe, family, etc go to that place you liked the most 3 or 4 years.

 

[engineeredout]

The legendary clinicians come from 5 year residencies. Just saying...

 

[surfdoc29]

This was several/many years ago, but St. John's in Detroit had third years doing 20 12s. Also, I think Newark-BI was 20x12 for third years.

20 12s as a senior sounds awful. I think these days that's more the exception than the norm though. Have not seen anywhere on the interview trail in 3 or 4 year residencies outside of a couple exceptions that has that heavy of a shift load past intern year.

 

[TheTruckGuy]

3 years. Trust me, you'll eventually get bored and repeat a lot in a 4 year.

 

[doggydog]

It's interesting to see how everyone is vehemently anti-four year programs vs. the programs that tend to be on top of everyone's rank list in each year's ROL thread.

Three years seems nice.

 

[deleted547339]

The legendary clinicians come from 5 year residencies. Just saying...

I thought in n out was only 3?

 

[BoardingDoc]

I thought in n out was only 3?

Everyone does the animal style fellowship though, so you may as well call it a 4 year.