Prestige vs Surgical volume

[AmurosisFugax]

If you had to choose between

a.) A small residency program with few residents but HIGH surgical volume, but doesn't have the prestige factor

vs

b.) A large residency program with many residents with drastically less surgical volume, but exceptionally renowed/prestigious.. but filled with felllows who are doing most of the cases....

What would you choose?

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[ophthoapp2010]

Choice B is not necessarily true - having a lot of fellows does not have to affect your surgical volume. At my program the patient for the fellows (private attending patients) and residents (county and VA patients) are completely separate, and there are plenty of cases to go around.

 

[JayZBlue]

Depends on what kind of career path you are interested in, and deciding which program would be able to take you where you want to be. Overall, I think the "prestigous" programs keep more doors open if you are undecided.

A and B sound very extreme; 99% of programs fall somewhere in the middle. I think high surgical volume programs carry prestige within ophthalmology because people who know know the strong clinical programs even if grandma doesn't. You need to look beyond the numbers though, because one high-volume residency can have awesome attendings while another doesn't. In the latter scenario, you'll be better off in a middle-volume program with better attendings and support. Conversely, I don't think any of the so-called "top ten" programs are as bad as you're making it sound. At the end of the day, it's the gut feeling you get when you interview at these programs.

 

[ophthope]

99% of programs fall somewhere in the middle.... At the end of the day, it's the gut feeling you get when you interview at these programs.

Agreed. Go with your gut feeling when you rank places. I took notes on every place, wrote down some of the surgical numbers, pros/cons of each program... except for the place I ranked #1. Because I knew it was going at the top of my list and I didn't need notes to help me decide that. #2 had sparse notes as well, because I was so interested at these places and so convinced that I wanted to be there that I didn't need the notes to help me decide.

If it's an accredited program, it will turn you into an Ophthalmologist. Go with your instincts when deciding. I'm sure glad that I did - I couldn't be happier with where I ended up. You aren't going to get good vibes from a place that tells you they're struggling to keep their surgical numbers up, or where the residents seemed unhappy, or where they saw so much trauma on call that they looked dead.

 

[AmurosisFugax]

I've already chosen A.). It's closer to home and 2x the volume of B.). I'm having second thoughts, but not much I can do at this point.

I put so much emphasis on volume as I figured the more I could do, the easier it would be.... and the more comfortable I would feel becoming a staff physician. I know I have probably shot myself in the foot in trying to get a great fellowship from going to school A.), but it is what it is.

Thanks for the responses so far.

 

[rocketbooster]

I've already chosen A.). It's closer to home and 2x the volume of B.). I'm having second thoughts, but not much I can do at this point.

I put so much emphasis on volume as I figured the more I could do, the easier it would be.... and the more comfortable I would feel becoming a staff physician. I know I have probably shot myself in the foot in trying to get a great fellowship from going to school A.), but it is what it is.

Thanks for the responses so far.

At the beginning of interview season I was ranking at the top all the programs with higher numbers. But then I started asking residents and attendings at every interview if numbers or diverse pathology were more important. They nearly always said pathology because you're going to do a million cataracts in practice anyway but will see the most diverse path in residency unless you work in academics. So they basically said having a county hospital was more important than a VA bc that's what gives you more path and autonomy while VA just gives you more cataracts. I should probably add that having a VA doesn't really matter if the program still has low numbers even with the VA. This seemed to be the case at most big city programs (most Chicago programs, most NYC programs, all DC programs - many had VAs but the numbers were still low). A top program is well known and usually has tons of path referred in too. Plus the prestige takes you a long a way.

Location aside, this ended up being the way I generally made my rank list:

1. Prestige (top 10-20)
2. County hospital and VA
3. County hospital
4. VA
5. Neither VA nor County

Location can easily move some of these around though.

 

[MstaKing10]

Volume can sometimes be misleading. If a resident claims to have done a case, even though they didn't do it start to finish, this can sometimes pad their numbers. Additionally, the types of cases done are also important. Hundreds of straightforward phaco's are equivalent to a fraction of complex phacos. How many of those cases were complex and how many of them were truly and honestly done completely by the resident is more important.

Ultimately, no prestigious program is going to train sub-par residents. You will receive excellent training, though the volume may be slightly less.

More important is what program seems to match best with your goals and learning style.

 

[LightBox]

I occasionally staff residents whose residency program probably is in the 99th percentile for cataract surgery volume. And I have to say, they are pretty good at cataract surgery. However, the residents barely do any other type of ophthalmic surgery. So when I watch them try to do anything else (e.g. pterygium, glaucoma, corneal transplants, etc), it is a somewhat painful experience to say the least.

I think that 200 or so cataracts during residency is plenty of experience. After those 200, I think it is better for the residents to get experience in other ophthalmic surgeries. For example, doing 20-30 trabs or tubes to replace 20-100 phacos.

 

[DrZeke]

I occasionally staff residents whose residency program probably is in the 99th percentile for cataract surgery volume. And I have to say, they are pretty good at cataract surgery. However, the residents barely do any other type of ophthalmic surgery. So when I watch them try to do anything else (e.g. pterygium, glaucoma, corneal transplants, etc), it is a somewhat painful experience to say the least.

I think that 200 or so cataracts during residency is plenty of experience. After those 200, I think it is better for the residents to get experience in other ophthalmic surgeries. For example, doing 20-30 trabs or tubes to replace 20-100 phacos.

How common is it to get 20-30 trabs or tubes in residency? I heard at some programs this is very hard to come by...

 

[dantt]

Ultimately, no prestigious program is going to train sub-par residents. You will receive excellent training, though the volume may be slightly less.

Unfortunately, not true. So called prestigious programs often take researchers...and train researchers. Compound this with low surgical volumes in a few of those places.

 

[OphthoApp]

As primary I did around 190 phacos, probably 20 glaucoma cases, 50 plastics cases, 40 peds cases, 10 retina cases, 5 cornea transplants, and too many pterygiums to count.

I agree you need a mixture of surgeries but I think you also need at least 140 phacos especially if you are going to just do comprehensive ophthalmology. 100 is not enough, because you are not comfortable doing complex cases at 100. By 140 I would say you feel more comfortable doing shallow chambers, small pupils, white cataracts, cases with zonular issues, ect. At programs doing only 100 residents are typically doing basic 1-3+ NS cataracts.

There are prestigious programs that are good residencies and prestigious programs that are known not to be good residencies. They are easy to spot, just talk to other applicants.

I am picking random numbers and am not sure what they correspond to but using for an example: If on rankings #12 program is a great residency and # 2 program is known as a terrible residency go to #12.

 

[LightBox]

How common is it to get 20-30 trabs or tubes in residency? I heard at some programs this is very hard to come by...

Probably not that common. I think if a place has a very busy (surgically) glaucoma fellowship, then there are likely a lot of glaucoma cases to go around. I think that many glaucoma attendings don't like to give out cases to residents because: (a) dealing with the aftermath of a botched filter is torture and (b) most residents don't express sincere interest in glaucoma patients or their long-term management.

 

[Corn Dog]

There are prestigious programs that are good residencies and prestigious programs that are known not to be good residencies. They are easy to spot, just talk to other applicants.

Would you be able to specify which "prestigious" programs are not known to be good residency programs?

I had a similar point of view last year before I went on the interview trail that many of the big name research programs would be weak clinically. However, that wasn't necessarily the case. I interviewed at many of the big name research programs, and they all focused primarily on clinical training and secondarily on research. They all seemed pretty solid clinically, while some were stronger than others.

If you could specify which programs you were referring to, I could comment on them accordingly.

 

[DrZeke]

Would you be able to specify which "prestigious" programs are not known to be good residency programs?

I had a similar point of view last year before I went on the interview trail that many of the big name research programs would be weak clinically. However, that wasn't necessarily the case. I interviewed at many of the big name research programs, and they all focused primarily on clinical training and secondarily on research. They all seemed pretty solid clinically, while some were stronger than others.

If you could specify which programs you were referring to, I could comment on them accordingly.

I matched to a middle tier program and have never had the impression that the top 10 programs put out poorly prepared surgeons. I think the rumor is that at some of these places "primary surgeon" for a procedure takes on a whole different meaning. I don't know how that's even possible.

Maybe a senior member can shed light on this?

 

[JayZBlue]

Unfortunately, not true. So called prestigious programs often take researchers...and train researchers. Compound this with low surgical volumes in a few of those places.

Many would disagree. The primary, and overarching, goal of ALL residencies is clinical training. At the "prestigious" programs, research (often clinical) is valued, but there is no compromise of clinic/OR time for research. The big name programs have diverse pathology and some of the best teachers, and many of the current clinical/surgical leaders in the field are products of these programs. I would also say that cataract volume is average to high at these programs, and not low or outrageously high. But surgical diversity would be top notch.

In regards to glaucoma numbers, the 2012 ACGME report says the national average was 10.2 trabs/tubes (range 0-52). And for cataract surgery, average was 152.8 (range 65-395). I highly doubt that the 0 and 65 were from any of the big name programs.

 

[LightBox]

I'll probably take some flak for this, but the "big name" programs that had notoriously low(er) surgical numbers (given their "fame") were Wilmer, Mass Eye and Ear, Cleveland Clinic, most of the NYC programs, etc). I think these low surgical numbers were especially true for some of the clinical fellowships (e.g Cornea-Wilmer and Retina-MEEI). But that was just their reputation several years ago when I was a resident/fellow -- it's anyone's guess what their true numbers are. Again, take my comment with a grain of salt -- just the overall "feel" from people on the interview trail, etc.

In general, I think that the highest surgical volumes are for programs located in the South. In these locations, there are ample indigent and immigrant patients that become the surgical patients of trainees. Programs like Bascom (and other FL programs), Baylor (and other TX programs like UTSW), UCLA, UCSD, Tulane, Emory, etc. are notorious for high caseloads. Also, Utah is/was known as having very high surgical volume for both residents and fellows, especially when they only had 2 residents per year. As a resident/fellow, there are positives and negatives from having "too-famous" attendings. The positive is that "famous" attendings have a lot of connections. The negative is that their patients may demand to only be operated by the famous attending, and not you, the lowly fellow.

Ok, time now to hear some verbal abuse from the Wilmer/MEEI clansmembers!

Btw, why did "rocketbooster" just get banned?

 

[OPPforlife]

Apparently some internet argument. The allopathic boards had a long drawn out apology from him...poor guy.


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[MEEI Res]

I'll probably take some flak for this, but the "big name" programs that had notoriously low(er) surgical numbers (given their "fame") were Wilmer, Mass Eye and Ear, Cleveland Clinic, most of the NYC programs, etc). I think these low surgical numbers were especially true for some of the clinical fellowships (e.g Cornea-Wilmer and Retina-MEEI). But that was just their reputation several years ago when I was a resident/fellow -- it's anyone's guess what their true numbers are. Again, take my comment with a grain of salt -- just the overall "feel" from people on the interview trail, etc.

In general, I think that the highest surgical volumes are for programs located in the South. In these locations, there are ample indigent and immigrant patients that become the surgical patients of trainees. Programs like Bascom (and other FL programs), Baylor (and other TX programs like UTSW), UCLA, UCSD, Tulane, Emory, etc. are notorious for high caseloads. Also, Utah is/was known as having very high surgical volume for both residents and fellows, especially when they only had 2 residents per year. As a resident/fellow, there are positives and negatives from having "too-famous" attendings. The positive is that "famous" attendings have a lot of connections. The negative is that their patients may demand to only be operated by the famous attending, and not you, the lowly fellow.

Ok, time now to hear some verbal abuse from the Wilmer/MEEI clansmembers!

Taking the bait 🙂 MEEI has become a high-volume residency while maintaining its strong academic roots. Recently posted about this: http://forums.studentdoctor.net/threads/massachusetts-eye-and-ear-infirmary.470662/. It’s unfortunate that negative reputations linger for years, if not decades.

To give you my numbers as primary surgeon: 230 cataracts (225 skin to skin, not padded primaries), 20 globes, 15 filtering/shunting procedures, 130 oculoplastics, 20 vits, 15 buckles, 30 strabs.

230 puts us up there with many of the other busy programs LightBox lists. I agree that “too-famous” attendings will attract demanding patients, but what surprised friends at other programs was that more than half of our primary phacos are with private attending patients. These are very high-yield. I’m obviously biased, but I think we are one of the best residencies for being one of the few programs that are both very strong clinically and academically.

Our retina fellowship is also mentioned, but similar to the residency, it's totally different from what it was a decade ago. The faculty is twice the size of what it was and the training is superb.

 

[dantt]

It’s unfortunate that negative reputations linger for years, if not decades.
.

Indeed. Rumor still floats around that there was a MEEI senior resident that was scrounging for enough PRP's to graduate.

 

[MEEI Res]

Indeed. Rumor still floats around that there was a MEEI senior resident that was scrounging for enough PRP's to graduate.

That was in the past also.
At 55-60 PRPs now and keeps increasing each year.

Not crazy high like hundreds but comfortably average. After the minimum of 20 though (soon will be 10), I think we've figured out how to do PRPs and don't need to necessarily do, or want to do, hundreds. Interesting how we don't have an injection requirement yet.

 

[backrow]

. Interesting how we don't have an injection requirement yet.

The requirements have been updated and there is a requirement for injections now (10 I think).

 

[MEEI Res]

The requirements have been updated and there is a requirement for injections now (10 I think).

Got it, thanks for the info!

 

[RestoreSight]

Taking the bait 🙂 MEEI has become a high-volume residency while maintaining its strong academic roots. Recently posted about this: http://forums.studentdoctor.net/threads/massachusetts-eye-and-ear-infirmary.470662/. It’s unfortunate that negative reputations linger for years, if not decades.

To give you my numbers as primary surgeon: 230 cataracts (225 skin to skin, not padded primaries), 20 globes, 15 filtering/shunting procedures, 130 oculoplastics, 20 vits, 15 buckles, 30 strabs.

230 puts us up there with many of the other busy programs LightBox lists. I agree that “too-famous” attendings will attract demanding patients, but what surprised friends at other programs was that more than half of our primary phacos are with private attending patients. These are very high-yield. I’m obviously biased, but I think we are one of the best residencies for being one of the few programs that are both very strong clinically and academically.

Our retina fellowship is also mentioned, but similar to the residency, it's totally different from what it was a decade ago. The faculty is twice the size of what it was and the training is superb.

sorry to say these numbers seem a little rich given you have 8-9 residents? 230 cataracts each x9 residents? Are you including Arivand cases? Those don't count towards your ACGME stats last I checked. 20 vits and 15 buckles as primary surgeon as a resident? When are you completing a complete vitrectomy from start to finish as a resident? Don't you have fellows? Don't mean to put you on the spot but my program has a huge referral network and our residents don't reach those numbers, especially in retina.

 

[OphthoApp]

The residents at MEEI do not have those primary retina numbers. There are six retina fellows.

 

[LightBox]

Taking the bait 🙂 MEEI has become a high-volume residency while maintaining its strong academic roots. Recently posted about this: http://forums.studentdoctor.net/threads/massachusetts-eye-and-ear-infirmary.470662/. It’s unfortunate that negative reputations linger for years, if not decades.

To give you my numbers as primary surgeon: 230 cataracts (225 skin to skin, not padded primaries), 20 globes, 15 filtering/shunting procedures, 130 oculoplastics, 20 vits, 15 buckles, 30 strabs.

230 puts us up there with many of the other busy programs LightBox lists. I agree that “too-famous” attendings will attract demanding patients, but what surprised friends at other programs was that more than half of our primary phacos are with private attending patients. These are very high-yield. I’m obviously biased, but I think we are one of the best residencies for being one of the few programs that are both very strong clinically and academically.

Our retina fellowship is also mentioned, but similar to the residency, it's totally different from what it was a decade ago. The faculty is twice the size of what it was and the training is superb.

That's great that MEEI's residency surgical numbers have improved. It seems like, in general, that the phaco #'s have increased significantly across most residency programs. I wonder if the cause of this sustained uptick is that residency program directors are comparing each other programs more, leading to a sort of competition. If so, that's great for trainees.

It's also great that your attendings shared their private patients with you while you were a resident. I call these "lay up" surgical cases because they take minimal scut work to generate. When I was a fellow, I performed ~300 cataracts which were >90% attending cases. It would have been way too much work (e.g. paperwork, bureaucracy, making sure patients got their scans, etc) to generate those surgical cases myself at the VA or the fellow clinic.

On the grand scope of things, the difference between 150 and 250 cataracts is really not that big of a deal. For an average general ophthalmologist, you will be likely doing around 500-1000 cataracts a year, making those 50 "missing" cataracts very miniscule.

Lastly, our counterparts in the U.K. (or other places like India) must be laughing at our cataract surgery numbers. I'm pretty sure that they average around 600 cataracts during their residency training! But I believe they lament that they do basically no other surgical procedures since the other stuff is done by the fellows.

 

[MEEI Res]

sorry to say these numbers seem a little rich given you have 8-9 residents? 230 cataracts each x9 residents? Are you including Arivand cases? Those don't count towards your ACGME stats last I checked. 20 vits and 15 buckles as primary surgeon as a resident? When are you completing a complete vitrectomy from start to finish as a resident? Don't you have fellows? Don't mean to put you on the spot but my program has a huge referral network and our residents don't reach those numbers, especially in retina.

Thanks for your input LightBox.

Regardless of what people may think, we have become a surgically busy ophthalmology department, and that’s all there is to it. There are at least 15-16 eye ORs going all day (5 in the MEEI surgery center, at least 1-2 in the main MEEI ORs, 4 at the newly opened Longwood MEEI ASC, 1 at Children’s, 1 at Children’s at Waltham, 1 at Beth Israel, 1 at the Boston VA, 1 at the Maine VA, and other places also), and the faculty size and affiliations have significantly increased in all subspecialities throughout the Harvard system – remember that we’re all over the Harvard hospitals, not just MEEI. Lots of EMR passwords to remember. The numbers are NOT including Aravind, where we do 20 SICSs. There are enough cases to go around, and the curriculum keeps updating to make sure residents are strategically assigned to absorb the volume. Individual experiences during residency obviously vary, and although I don’t know exact numbers for my classmates, I’m probably on the higher end for phacos and retina (fyi OpthoApp, we also do retina outside of MEEI where there are no fellows), but lower on glaucoma and strabs, and average plastics and globes. There are fellow cases, there are resident cases, and things that we work on together. The fellows are almost exclusively at MEEI, so residents do everything at the affiliate hospitals, where there are subspecialty attendings also. MEEI is 8 a year. Some of the other “high volume” big programs with many fellows that are listed above have similar numbers also (some with more, even in retina), so it’s possible. Anyway, I just wanted prospective applicants to know that we have very good surgical volume, so it should not be a concern, and please consider applying and interviewing. More importantly, let’s go back to enjoying Orlando.

 

[ophtho838]

Back to the OP's question, I don't really think it's too big of a deal which one you choose. Most programs have tailored their class sizes to their overall surgical volume (i.e. programs won't have 8 residents if each resident would only be getting 70 phacos). The grand majority of programs range in the mid-to-high 100's (maybe less in saturated cities like NYC). Within this range I've been told your surgical skills don't change drastically, so if you chose a more academic/prestigious program at the lower end of this range I don't think it would make a big difference clinically. There are only a handful of programs with sky high surgical #'s (Utah, UCLA, Baylor, UTSW, Bascom, Emory come to mind) and any of these will set you up well for fellowships, so you wouldn't be hurting if you opted for one of these either. In the end it all comes down to where you feel most comfortable and where you can learn best.

 

[dantt]

On the grand scope of things, the difference between 150 and 250 cataracts is really not that big of a deal. For an average general ophthalmologist, you will be likely doing around 500-1000 cataracts a year, making those 50 "missing" cataracts very miniscule.

It's important for applicants to realize though while the difference between 150 and 250 is not huge...the difference between 150 and 100 or even 86 is huge. (Rumor circles northwestern's and a few new york program's numbers are "too low to publish online" and one must add the program to one's "cart," i.e. interview, in order to find out). You will definitely not be doing 500-1000 cataracts a year when you start out and that's when your former surgical training will matter the most.