Programs on the up or downswing?

[EMRocksmyworld]

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Just to be clear, this is NOT a "what are the best programs in EM?" thread! 😛

I have heard some claims on the interview trail that some of the traditionally amazing EM programs (which are located at somewhat less prestigious hospitals) have reached their "peak" and are headed downwards, while newer programs at big-name Ivy League/California institutions are on their way up in terms of prestige. Obviously I would not base my residency choice on this, but I'm curious as to whether other people have heard similar things, and if you think there's any truth to it. Any thoughts?

 

[VO2]

Just to be clear, this is NOT a "what are the best programs in EM?" thread! 😛

I have heard some claims on the interview trail that some of the traditionally amazing EM programs (which are located at somewhat less prestigious hospitals) have reached their "peak" and are headed downwards, while newer programs at big-name Ivy League/California institutions are on their way up in terms of prestige. Obviously I would not base my residency choice on this, but I'm curious as to whether other people have heard similar things, and if you think there's any truth to it. Any thoughts?

I've been led to believe that the relative prestige of a program is derived primarily by the connections and alma mater make-up present at the place one hopes to land a job.

 

[EMRocksmyworld]

I've been led to believe that the relative prestige of a program is derived primarily by the connections and alma mater make-up present at the place one hopes to land a job.

That certainly makes sense. So do you mean that more established programs may simply provide a larger network for post-residency job seeking, or that it is really dependent on geography?

In starting this thread, I was attempting to initiate a discussion about the validity of the claim that older, more established programs may be "on the way out," while newer programs at very well-known medical institutions are gaining ground. As we all know, many specialities like IM and General Surgery have their most renowned programs at Ivy League institutions. With EM being a newer specialty, the programs traditionally considered to be the strongest are (in general) at lesser known medical centers. However, now that EM programs have been established at hugely renowned hospitals, do you think that those will surpass the older powerhouse programs in reputation?

While I realize that there is no "best" program (as per the hundreds of threads debating such on SDN) and that prestige only means as much as your ego wants it to, I am intrigued by the idea that in a very general sense, the old "original" programs are being surpassed by newer Ivy League programs.

I personally don't think that I agree with this claim, but of course I am just starting out in the EM world and obviously don't have a crystal ball. Regardless, I have heard this discussed a lot on the interview trail and am really interested in other people's opinions. What does everyone think?

 

[gutonc]

However, now that EM programs have been established at hugely renowned hospitals, do you think that those will surpass the older powerhouse programs in reputation?

Yes. For the simple reason that med students (even those down-to-earth EM-bound ones) are prestige ******.

But it's not like it's going to happen tonight.

Tomorrow maybe...keep a close eye out.

 

[Xerxes1729]

If an institution like Harvard or Yale throws its substantial resources behind building an excellent EM program, it's probably going to succeed. Once you start recruiting top-tier residents and faculty, it's going to tend to snowball, since many of those people want to work with other, similarly successful people. Plus, many of these institutions are in highly desirable locations, as opposed to many of the traditionally strong EM programs, e.g., Boston versus Cincinnati.

 

[old_boy]

If an institution like Harvard or Yale throws its substantial resources behind building an excellent EM program, it's probably going to succeed. Once you start recruiting top-tier residents and faculty, it's going to tend to snowball, since many of those people want to work with other, similarly successful people. Plus, many of these institutions are in highly desirable locations, as opposed to many of the traditionally strong EM programs, e.g., Boston versus Cincinnati.

There are already examples of this. UCSF comes to mind - already superstar residents and only in their third year.

 

[emermed]

If an institution like Harvard or Yale throws its substantial resources behind building an excellent EM program, it's probably going to succeed. Once you start recruiting top-tier residents and faculty, it's going to tend to snowball, since many of those people want to work with other, similarly successful people. Plus, many of these institutions are in highly desirable locations, as opposed to many of the traditionally strong EM programs, e.g., Boston versus Cincinnati.

I think the problem with this type of thinking is that a lot of what makes for good training in EM is patient population. Many of the Ivy/prestige names (although certainly not all) have EDs that no matter how many great faculty you put in there are not going to be as good as some lesser name places.

 

[Venko]

I think the problem with this type of thinking is that a lot of what makes for good training in EM is patient population. Many of the Ivy/prestige names (although certainly not all) have EDs that no matter how many great faculty you put in there are not going to be as good as some lesser name places.

Accepting that I am going away from the original post, and I apologize if this starts some tangential discussion...but...

obviously this is an area of debate, but I think many of the Harvard's the Yale's etc have fantastic patient populations that utilize their EDs. I personally think too many poeple think of trauma as EM and look for urban populations etc. Yes, there is decompensated diabetes there, and violent crime, but its not really all that difficult to take care. There is very little mental challenge in these patients.

The patients who are quite challenging are those that have had multiple complex medical problems as well as some acute change. For example a liver transplant recipient who comes in with abdominal pain. Or those who have dialysis from small vessel vasculitis and are undergoing aggressive immunomodulation and now come in to the ED with malaise. These are difficult cases with a lot of components that need to be addressed by the ED doc. These are the patients seen in the harvards the yales, the cleveland clinics, etc.

You wont find a very high concentration of these patients in some of the classically thought of "great" EM programs.

This is just my opinion and I am biased by my residency experiences. With that said, I have been working in three EDs since graduation and they dont really have anything close the same pathology or concentration of sick patients as to what I saw in my residency. Yet, they are of the county, VA, community variety.

My $0.02

TL

 

[energy_girl]

Accepting that I am going away from the original post, and I apologize if this starts some tangential discussion...but...

obviously this is an area of debate, but I think many of the Harvard's the Yale's etc have fantastic patient populations that utilize their EDs. I personally think too many poeple think of trauma as EM and look for urban populations etc. Yes, there is decompensated diabetes there, and violent crime, but its not really all that difficult to take care. There is very little mental challenge in these patients.

The patients who are quite challenging are those that have had multiple complex medical problems as well as some acute change. For example a liver transplant recipient who comes in with abdominal pain. Or those who have dialysis from small vessel vasculitis and are undergoing aggressive immunomodulation and now come in to the ED with malaise. These are difficult cases with a lot of components that need to be addressed by the ED doc. These are the patients seen in the harvards the yales, the cleveland clinics, etc.

You wont find a very high concentration of these patients in some of the classically thought of "great" EM programs.

This is just my opinion and I am biased by my residency experiences. With that said, I have been working in three EDs since graduation and they dont really have anything close the same pathology or concentration of sick patients as to what I saw in my residency. Yet, they are of the county, VA, community variety.

My $0.02

TL

I agree with TL. One of the other things that I've really liked about my program is that we have great off-service rotations and amazingly smart colleagues and teachers in IM, surgery, neuro, peds, etc. Some people may like it when the ED residents run off-service rotations, but I actually like it that when I'm in the PICU, SICU, ortho, whatever, that I am the person who has most to learn. After all, the best to time to be on the steep part of the learning curve is as a resident! And I learn a lot from the various consultants we have, and for the complex patients as TL mentioned. My program--and I assume some of the other newer academic programs too--has a lot of room to grow, and the resources and the institutional support to do it.

Of course, there's always a trade-off. Strong off-services could mean that the ED resident does less. I also am not trained in decisions like when to transfer, and I am used to calling in-house consultants instead of figuring things out myself. More research opportunities is good for some, but often means one extra year of training. So to each their own. I think most applicants know going in what kind of program attracts them. I'm not sure that the traditionally strong programs are on the downswing (all evidence points to them being on the upswing too), but I do think that the academic programs are getting better every year.

 

[EMRocksmyworld]

Thanks for the responses!! They're very helpful and make a lot of sense. What if you aren't sure what kind of training you want though? I see benefits to both the strong academic programs and also the hardcore county-style programs. My EM rotations were at academic places (in hindsight, not the best idea), so I don't have a strong sense outside of interview day what the county-style programs are like on a day-to-day basis. Everyone says that most applicants know what type of training program they want, but what if I don't? How do I figure it out by February? Or can I really just decide based on "gut instinct" and not worry about the type of program?

 

[Pure Anergy]

Thanks for the responses!! They're very helpful and make a lot of sense. What if you aren't sure what kind of training you want though? I see benefits to both the strong academic programs and also the hardcore county-style programs. My EM rotations were at academic places (in hindsight, not the best idea), so I don't have a strong sense outside of interview day what the county-style programs are like on a day-to-day basis. Everyone says that most applicants know what type of training program they want, but what if I don't? How do I figure it out by February? Or can I really just decide based on "gut instinct" and not worry about the type of program?

Even if you spent four weeks rotating at a hardcore county hospital, you'd still be basing your decision on incomplete information. That's because you'd be a medical student rotater trying to figure out what training is like there at the resident level. Is there really such a thing as a pure county program versus an academic program anyway? Some hospitals are clearly combo county and academic because they're the only game in town. Plus most county programs are affiliated with academic centers and community hospitals. Most academic centers have residents rotate through county and community hospitals. Not to say that there isn't a difference in emphasis based on what kind of hospital hosts the program, but there is a ton of overlap.

If you buy in to the idea that every program meets basic minimum standards and will prepare you well for the practice of EM, then it seems reasonable to conclude that yes, you should pick by gut instinct or some other personal preference like location. Of course there's no guarantee that in hindsight you might have picked differently. But on the other hand, you probably don't only have one "right" choice, either. In other words, you could probably be happy at several programs, and you'll still be happy even if you end up at good fit C versus good fits B and A.

 

[iridesingltrack]

OP,

Disclaimer: I am a resident in one of the older programs.

I do not believe the old school programs are on a "downswing" based on the quality of the faculty, graduates, residents, or applicants, variables that predict reputation. The newer programs are definitely on a steep upward trajectory owing, in part, to their newness (i.e. if a program is new, it doesn't have any reputation so it must grow.). However, with the growing number of overall applicants, and therefore, the greater number of quality applicants one programs growth doesn't hurt other programs. It is very good for EM to have such high quality programs throughout the country.

The term "prestige" in the initial post threw me aback on my first reading. After some thought, I took it to mean a positive reputation. Reputation should be based on the product: what do the graduates do in their careers, what jobs do they get etc; in addition, consider the current residents when you interview. This can be hard to get a handle on as it is obviously nebulous and full of subjectivity. Program reputation should not be a primary concern as this will only get a graduate so far, then they must rely on their own reputation. As with anything in life, one will get out of residency what they put into it. I believe that clinical excellence can occur at every program in the country; it is up to the resident.

I do find the contrast between "academic" and "county" to be odd, however. In terms of research dollars from the NIH, one Ivy is in the top 25 (UPenn at #4). The second most flush program overall with NIH dollars is Emory which is obviously a heavily county program (NIH funding for 2009, see EM programs: http://www.brimr.org/NIH_Awards/2009/NIH_Awards_2009.htm). The point is that every program is academic; they are all teaching and doing research. So, I am not sure what the above posters mean by this comparison. In terms of pt populations, "county" often translates to poor and under-served. Academic translates to lots of consultants to call. You will see plenty of complicated pts regardless of where you go: some will be transplants, some will be undifferentiated hypotension, some (gasp) will be trauma.

EMRocks, in terms of choosing the place you want to train, consider how you learn (this is important as programs have very different teaching styles), where you want to live (short-term and long-term-these may be different) and what your goals are then find the place that provides what you are looking for. I know it is easier said than done. You'll figure it out. I promise.

Good luck,
iride

 

[xaelia]

I would also suggest that the research dollars rankings from the NIH have little bearing on resident training. They more appropriately reflect the environment and departmental support for faculty research. You may be able to make associations from NIH funding to faculty prestige/intelligence or research opportunities, but the extent to which it impacts resident training or opportunities may be less noticeable. It may additionally be possible to argue that the best researchers are not the best clinicians or clinician-educators.

 

[iridesingltrack]

I would also suggest that the research dollars rankings from the NIH have little bearing on resident training. They more appropriately reflect the environment and departmental support for faculty research. You may be able to make associations from NIH funding to faculty prestige/intelligence or research opportunities, but the extent to which it impacts resident training or opportunities may be less noticeable. It may additionally be possible to argue that the best researchers are not the best clinicians or clinician-educators.

I agree with everything above.

 

[EMRocksmyworld]

Thanks for all of the info and the reassuranace, iride. You definitely interpreted my use of "prestige" as intended. Great things to think about- thank you so much!

OP,

Disclaimer: I am a resident in one of the older programs.

I do not believe the old school programs are on a "downswing" based on the quality of the faculty, graduates, residents, or applicants, variables that predict reputation. The newer programs are definitely on a steep upward trajectory owing, in part, to their newness (i.e. if a program is new, it doesn't have any reputation so it must grow.). However, with the growing number of overall applicants, and therefore, the greater number of quality applicants one programs growth doesn't hurt other programs. It is very good for EM to have such high quality programs throughout the country.

The term "prestige" in the initial post threw me aback on my first reading. After some thought, I took it to mean a positive reputation. Reputation should be based on the product: what do the graduates do in their careers, what jobs do they get etc; in addition, consider the current residents when you interview. This can be hard to get a handle on as it is obviously nebulous and full of subjectivity. Program reputation should not be a primary concern as this will only get a graduate so far, then they must rely on their own reputation. As with anything in life, one will get out of residency what they put into it. I believe that clinical excellence can occur at every program in the country; it is up to the resident.

I do find the contrast between "academic" and "county" to be odd, however. In terms of research dollars from the NIH, one Ivy is in the top 25 (UPenn at #4). The second most flush program overall with NIH dollars is Emory which is obviously a heavily county program (NIH funding for 2009, see EM programs: http://www.brimr.org/NIH_Awards/2009/NIH_Awards_2009.htm). The point is that every program is academic; they are all teaching and doing research. So, I am not sure what the above posters mean by this comparison. In terms of pt populations, "county" often translates to poor and under-served. Academic translates to lots of consultants to call. You will see plenty of complicated pts regardless of where you go: some will be transplants, some will be undifferentiated hypotension, some (gasp) will be trauma.

EMRocks, in terms of choosing the place you want to train, consider how you learn (this is important as programs have very different teaching styles), where you want to live (short-term and long-term-these may be different) and what your goals are then find the place that provides what you are looking for. I know it is easier said than done. You'll figure it out. I promise.

Good luck,
iride