Radiology: resident-driven program vs fellow-heavy program

[radapplicant2016]

Multiple radiology advisers and residents have suggested that "residency-driven" programs provide a better radiology training experience, as opposed to "fellow-driven" programs. For example, people state that residency-driven programs generate residents that are better able to act independently and thus are sought after by fellowship programs and practices. Obviously many of the top ranked programs (e.g., MGH, UCSF, Wash U) are fellow-heavy, and these programs have the definite benefits of the best research opportunities and training with the most renowned experts. But is there really deficient clinical training given the abundance of fellows at these programs?

The possible benefit of training in a resident-driven program seems to make sense though I am wondering if it really pans out. Does anyone have first- or second-hand experience in each of these two types of programs in order to compare what, if any, difference there is in resident training?

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[maxxor]

Multiple radiology advisers and residents have suggested that "residency-driven" programs provide a better radiology training experience, as opposed to "fellow-driven" programs. For example, people state that residency-driven programs generate residents that are better able to act independently and thus are sought after by fellowship programs and practices. Obviously many of the top ranked programs (e.g., MGH, UCSF, Wash U) are fellow-heavy, and these programs have the definite benefits of the best research opportunities and training with the most renowned experts. But is there really deficient clinical training given the abundance of fellows at these programs?

The possible benefit of training in a resident-driven program seems to make sense though I am wondering if it really pans out. Does anyone have first- or second-hand experience in each of these two types of programs in order to compare what, if any, difference there is in resident training?

Why don't you give an example of a resident driven program?

 

[radapplicant2016]

Advisers in California have given examples of UCSF, UCLA, and UCSD being relatively more fellow-driven and UC-Davis, UC-Irvine, and LLU being more resident-driven. Obviously there is a gray zone and the "fellow-effect" would vary by sub-specialty department.

I don't claim to know anything about this issue, hence I am reporting what I have been told. I appreciate any input/advice from those that are informed.

 

[radapplicant2016]

A more specific follow-up question:

Have any residents working in fellow-heavy departments felt that their training was affected for better or worse compared to training environments involving just a resident and attending (within the same residency program)?

For example, does the resident have limited responsibilities or roles, or less opportunity to gain experience with cases or procedures, etc.

 

[deleted564680]

When I was applying/interviewing, I was at numerous programs where the residents stated that they took a back-seat to the fellows. I don't want to name programs but you can take a look at fellow/resident ratio and it seems that the more "academic" the program, the more the program is centered on fellows.
HOWEVER, huge caveat here is that these same residents did not mind because they felt that they would be able to be a fellow at said program(s) and that was their ultimate goal anyway. It was kind of like biding your time as a resident to get to be the fellow someday.

 

[Gadofosveset]

It'd be best to be in a place with a few fellows, but not too many.

It's a very good thing to consider, and there are a lot of ins and outs. The goal is to see as much as you can and practice as much as you can before you graduate. You also want to pass your boards and have some time to read.

Pro-fellow:
- You and your co-residents don't bear the weight of the entire volume
- Tend to be larger programs, so even in the worst case scenario, and you're left with scraps, they're interesting referral-center scraps.
- Depending on the program, some programs coddle their residents and drive their fellows hard, so it could be a very relaxed residency.
- Sometimes fellows can be more in touch with the residents and more approachable with questions. They can be an extra-learning resource, esp. if "great teacher" X doesn't actually teach much.

Con-fellow:
- They'll take most of the interesting cases. They also take the more difficult cases, which may seem great early on, but it kind of weakens you over time and you start to think that someone else will take all the difficult stuff, which doesn't help you mature.
- Attendings in some institutions will spend all their time teaching the fellows and basically ignore the residents. This becomes a vicious circle because residents in some fellow-driven programs then don't accept responsibility for the list and the attending sorta thinks of them as extraneous... which they are.
- The resident will get more procedure time if there are no fellows.

The resident/fellow "culture" varies from place to place (and maybe even from department to department within a single institution). It's a good thing to ask residents about on the interview trail.

 

[Gadofosveset]

Also... my personal opinion is that I wouldn't avoid an academic program because it has fellows to go to a small program that's just using residents for labor because you supposedly would get "valuable" training experience without fellows. This is not a better option over the long term, unless the attendings at this theoretical program are committed to teaching you well... then it would be awesome.

If you're driving through a bunch of boring cases because it's a small center with no fellows and getting ignored in a community residency program because they're not "academic" types... I would argue that this kind of "experience" is not good for your career.

 

[shark2000]

Also... my personal opinion is that I wouldn't avoid an academic program because it has fellows to go to a small program that's just using residents for labor because you supposedly would get "valuable" training experience without fellows. This is not a better option over the long term, unless the attendings at this theoretical program are committed to teaching you well... then it would be awesome.

If you're driving through a bunch of boring cases because it's a small center with no fellows and getting ignored in a community residency program because they're not "academic" types... I would argue that this kind of "experience" is not good for your career.

Exactly.

Programs have lots of fellows for good reasons. The main reason is their volume and more importantly the diversity of their cases. What is the point of reading 100 normal head CTs with a few strokes and head bleeds in between?

I agree that the residents of community programs can dictate faster than residents of big programs upon completion of their training. I don't think they are sought after more. The speed comes very fast after working in pp for a year. Some people never get to the speed.

The advantages of big academic center that you can hardly have in a small community program:

1- Better fellowship placement. I know that someone will come and say that how the residents of their community program do great in finding a fellowship. Good for them. But for some competitive fellowships, the residents of bigger programs have an edge.

2- Connections: Very important. You will be trained by some of the well known people in the field. If 10 years down the road you feel that you want to change your career or you need some professional help, these people are there to help you. Not the case in small community residencies that may or may not exist in 10 years.

3- Network: Similar to number 3. But these big programs have 20-30 fellows a year. It is kind of a small society by itself and you are a member of it.

4- Diversity of cases: As I mentioned volume is not important per se. The diversity is more important.

5- Subspecialty training: Does not mean that you attending is fellowship trained. It means that your attending is a pioneer in the field.


At the end of the day, in the long run these things do not really matter. It is like the effect of your high school score on the program that you match for residency. If you are good, sooner or later you will find your way. A graduate of an average program can easily be more successful than the graduate of MGH if he is better and if he wants it.

I have seen so many F.. uped reports by people who were trained at UCSF or MGH and I have seen a lot of excellent reports by older general radiologists who were trained at a small program in 80s. 10 years after you start your career, your skills will highly depend on things that you do after you finish fellowship.

 

[meister]

Your initial job search is probably helped with better names on your CV, but you can get some of that to a certain extent via fellowship. The connections you make can also help tremendously for jobs and are not easily replaced.

 

[radapplicant2016]

Thanks for all of the advice! I really appreciate the detailed considerations of pros/cons and what to look for in a residency program. You all are awesome!

 

[Lavan]

There choice between big academic and small community is a bit of false comparison however for applicants competitive enough to match at large academic programs. There are of course large academic programs that are resident driven. One might argue that these offer the best training (or at least the most balanced benefits/deficits) and are plenty big enough name wise/contact-wise for practice, at least regionally (academic pedigree for the high-powered academic career trajectory notwithstanding).

 

[Gadofosveset]

There choice between big academic and small community is a bit of false comparison however for applicants competitive enough to match at large academic programs. There are of course large academic programs that are resident driven. One might argue that these offer the best training (or at least the most balanced benefits/deficits) and are plenty big enough name wise/contact-wise for practice, at least regionally (academic pedigree for the high-powered academic career trajectory notwithstanding).

Not necessarily a false comparison, when you take two important things into account:

1) "research": some med students equate a large academic center with research and lack of practical ability. If their goals are primarily private practice, then they may choose a community program for the supposed better OJT. I know very high stat med students who have made this deliberate choice. This is not a good choice, IMO.

2) location: If you have to choose between small program with poor training in awesome city / market you want to get connections in vs. large program with excellent training in lame city/town, then this is a real dilemma. I would recommend getting better training for 4 years and then relocating for fellowship, but everyone's priorities are different.

 

[Lavan]

Fair enough on #2. I was responding to OP's question about the training merits of the resident and fellow-driven. Obviously in real life, location is an important (if not the most important) consideration. If one is choosing poor training for good location though, it's not really about which has the better training, it's about your priorities for your life for those four years.

As for point one, that's just sad reasoning. I've personally never met anyone who has picked a program that way, though I could see some who might add that to their justification when choosing location > quality. A program needs to be judged on its own merits, plenty of academic programs have nominal research but high volume, resident-driven, etc.

 

[Gadofosveset]

Fair enough on #2. I was responding to OP's question about the training merits of the resident and fellow-driven. Obviously in real life, location is an important (if not the most important) consideration. If one is choosing poor training for good location though, it's not really about which has the better training, it's about your priorities for your life for those four years.

As for point one, that's just sad reasoning. I've personally never met anyone who has picked a program that way, though I could see some who might add that to their justification when choosing location > quality. A program needs to be judged on its own merits, plenty of academic programs have nominal research but high volume, resident-driven, etc.

I chose my program that way, and so did others from my graduating med school class. We were helped in the decision by bad advice about the relative merits of academic vs. community programs, from people who should have known better. Your assumption that the relative merits of the two pathways is self-evident is incorrect; I know that this particular bad advice exists, and it can be pitched very persuasively, although it is less common then it was approximately a decade ago.

 

[Gadofosveset]

Also, I've heard variations of the OJT benefit of community programs from residency applicants over the past few years (although usually brought up to dismiss it: "I know that a community program might give me an opportunity to develop speed in a real life setting, but I think I would benefit more from your institution because... x"). The division between academic and community programs in this respect is real in the minds of some applicants. I think we agree that it is not a worthwhile way to judge programs for training and that a "resident-driven" academic program is probably the best of both worlds for training... although residents at these programs tend to be the most unhappy in my experience since they shoulder both a lot of volume *and* academic expectations.

 

[chronicidal]

What about attending/staff-driven programs, where it wouldn't make much of a difference if all the residents went on strike?

 

[Radiologyreviews2015]

What about attending/staff-driven programs, where it wouldn't make much of a difference if all the residents went on strike?

I'd also like to know this.

Just an applicant now, but my first impression was that this set-up was ideal because they at least have a good volume to resident ratio to need so many attendings. It seems like a resident could read more volume if they wanted to, but not be pressured to complete any list. I don't know if those programs lend themselves to being more 'didactics-focused' than 'volume-focused' and if so, whether or not that would be a good/bad thing.

 

[Radiologyreviews2015]

I'd also like to know this.

Just an applicant now, but my first impression was that this set-up was ideal because they at least have a good volume to resident ratio to need so many attendings. It seems like a resident could read more volume if they wanted to, but not be pressured to complete any list. I don't know if those programs lend themselves to being more 'didactics-focused' than 'volume-focused' and if so, whether or not that would be a good/bad thing.

Heard from residents at Cleveland Clinic that their set up is attending-driven. Pro is that they have lots of volume and case complexity but you don't have pressure to grind through the list. Con is that you don't have pressure to grind through the list and you can easily find yourself in a position where the non-teaching attending on the same service sitting in a separate room is eating all your volume and you lose out on the experience of "running the service" whatever that means.

 

[deleted564680]

Heard from residents at Cleveland Clinic that their set up is attending-driven. Pro is that they have lots of volume and case complexity but you don't have pressure to grind through the list. Con is that you don't have pressure to grind through the list and you can easily find yourself in a position where the non-teaching attending on the same service sitting in a separate room is eating all your volume and you lose out on the experience of "running the service" whatever that means.

Seems pretty sweet to me. You can do as many cases as you want but don't have to stay late/feel pressured for no reason other than to "clear the list." I'm sure a place like CCF has enough volume to where other attendings won't steal a lot ha. Plus, I've watched most attendings read and they don't necessarily pick the lengthy/difficult studies all the time like a fellow would. Attendings have already made their job, but I guess some could be mean and not like residents.

 

[shark2000]

Seems pretty sweet to me. You can do as many cases as you want but don't have to stay late/feel pressured for no reason other than to "clear the list." I'm sure a place like CCF has enough volume to where other attendings won't steal a lot ha. Plus, I've watched most attendings read and they don't necessarily pick the lengthy/difficult studies all the time like a fellow would. Attendings have already made their job, but I guess some could be mean and not like residents.

With this mindset you will become a terrible radiologist.

A certain level of pressure is always needed for good education.

 

[dr seuss]

With this mindset you will become a terrible radiologist.

A certain level of pressure is always needed for good education.

Pressure is important, but I disagree that you always need it.

My residency would be considered "attending-driven". There is a lot more volume than the residents could handle, but we have so many attendings that it is still low volume per attending. Monday through Friday the focus is on education: the attendings have plenty of time to teach, and it is okay on outpatient rotations if the list isn't clear because someone comes in on the weekend to finish everything. On inpatient rotations everything has to be read, but the pressure isn't solely on the resident because the attending will help. Our call shifts are very busy and we have a ton of internal moonlighting, so there are still times when we have to read fast. Depending on how much moonlighting you want to do and how fast you read during the day, it can be a very high volume residency. There is the potential for someone who doesn't want to work hard to get by without doing much, but I would argue that that type of person wouldn't become a good radiologist no matter where they trained.

I think it was you who posted (maybe on auntminnie) that one of the things they like about their job was that at the end of the shift they can leave even if the list isn't clear, and if there was a complex case, they could take their time and do a good job on it instead of worrying about clearing the list. One of the things I like about my program is that whenever I need to, I can take my time and look things up when I have interesting cases, but at the same time the volume is high enough that I never have to sit there waiting for something to come up on the list.

Every day when I get up I don't dread going to work because at my residency the focus is on education and not clearing the list. Residency is a 4 year job and quality of life still matters during those years.

 

[shark2000]

Pressure is important, but I disagree that you always need it.

My residency would be considered "attending-driven". There is a lot more volume than the residents could handle, but we have so many attendings that it is still low volume per attending. Monday through Friday the focus is on education: the attendings have plenty of time to teach, and it is okay on outpatient rotations if the list isn't clear because someone comes in on the weekend to finish everything. On inpatient rotations everything has to be read, but the pressure isn't solely on the resident because the attending will help. Our call shifts are very busy and we have a ton of internal moonlighting, so there are still times when we have to read fast. Depending on how much moonlighting you want to do and how fast you read during the day, it can be a very high volume residency. There is the potential for someone who doesn't want to work hard to get by without doing much, but I would argue that that type of person wouldn't become a good radiologist no matter where they trained.

I think it was you who posted (maybe on auntminnie) that one of the things they like about their job was that at the end of the shift they can leave even if the list isn't clear, and if there was a complex case, they could take their time and do a good job on it instead of worrying about clearing the list. One of the things I like about my program is that whenever I need to, I can take my time and look things up when I have interesting cases, but at the same time the volume is high enough that I never have to sit there waiting for something to come up on the list.

Every day when I get up I don't dread going to work because at my residency the focus is on education and not clearing the list. Residency is a 4 year job and quality of life still matters during those years.

Your post is full of cliches and wrong conclusions. It seems you want to convince yourself (more than us) that you are going to a great program.

Your description is typical for many private practice pseudo-academic programs. I don't say there are not good radiologists coming out of these programs, but on average they are not a good place to do your training and their trainees are below the average.

 

[Fab5Hill33]

100% spot on.

With this mindset you will become a terrible radiologist.

A certain level of pressure is always needed for good education.

 

[scootad.]

You want to be the solo guy on call, with the surgeon and trauma team breathing down your neck asking you "so, do we need to operate or not??" This is the kind of pressure you need to become a good, confident, decisive radiologist.

 

[qxrt]

You want to be the solo guy on call, with the surgeon and trauma team breathing down your neck asking you "so, do we need to operate or not??" This is the kind of pressure you need to become a good, confident, decisive radiologist.

Eh, I disagree. The kind of pressure that's more relevant to radiology nowadays is that of trying to grind through an ever-growing worklist while getting interrupted by phone calls from clinicians requesting prelim reads, while the technologist is on another line requesting protocol clarification, and you have a clinical team behind you wanting to review a case. Dealing with the pressure of prioritizing and multi-tasking under a crushing workload is the most important skill to learn when you're on call.

Compared to that pressure, the pressure of learning to decide whether something represents dangerous pathology or something benign is the whole point of radiology residency and not relatively as bad, even with the surgeon and trauma team standing right behind you, as long as you have a good baseline of knowledge. Sometimes when a finding is borderline or unclear, you need to hedge and/or recommend clinical correlation, and done within reasonable limits, this does not make you a bad radiologist. The pressure of having to make a critical life-saving decision is more relevant when you are a junior resident who is not very comfortable reading certain studies due to lack of experience. By the time you are a senior resident, you should have enough exposure just through your clinical workday and call experience to make this kind of decision.

When you have that baseline of experience and knowledge, there is not as much difference between relaying a critical finding through a dictated report and phone call versus while the surgery team is behind you.

 

[shark2000]

Eh, I disagree. The kind of pressure that's more relevant to radiology nowadays is that of trying to grind through an ever-growing worklist while getting interrupted by phone calls from clinicians requesting prelim reads, while the technologist is on another line requesting protocol clarification, and you have a clinical team behind you wanting to review a case. Dealing with the pressure of prioritizing and multi-tasking under a crushing workload is the most important skill to learn when you're on call.

Compared to that pressure, the pressure of learning to decide whether something represents dangerous pathology or something benign is the whole point of radiology residency and not relatively as bad, even with the surgeon and trauma team standing right behind you, as long as you have a good baseline of knowledge. Sometimes when a finding is borderline or unclear, you need to hedge and/or recommend clinical correlation, and done within reasonable limits, this does not make you a bad radiologist. The pressure of having to make a critical life-saving decision is more relevant when you are a junior resident who is not very comfortable reading certain studies due to lack of experience. By the time you are a senior resident, you should have enough exposure just through your clinical workday and call experience to make this kind of decision.

When you have that baseline of experience and knowledge, there is not as much difference between relaying a critical finding through a dictated report and phone call versus while the surgery team is behind you.

Your post is full of cliches and justifications that I disagree with them. I totally agree with what scootad says.

As a recommendation, if this is your view of radiology educate yourself better for your first job. It seems you are not ready for it. You don't know what you don't know.

Speed will come during the first year of private practice but quality won't.

 

[qxrt]

Your post is full of cliches and justifications that I disagree with them. I totally agree with what scootad says.

As a recommendation, if this is your view of radiology educate yourself better for your first job. It seems you are not ready for it. You don't know what you don't know.

Speed will come during the first year of private practice but quality won't.

Please cool it with the condescending and personal attacks. You do not see me insulting you or anyone else here regardless of whether I agree or disagree, do you?

 

[scootad.]

I think the point we are making is there is a ton of value in being the final arbriter of important decisions…middle of the night decisions that determine whether someone goes to surgery or not. Decisions where the buck stops with you.

When I think back to my residency days, the cases I learned the most from were my on-call misses. The ones where I failed to make a finding that perhaps delayed an important surgery for a patient, overcalled something resulting in over-treatment of the patient, and so forth. I really took those cases to heart and vowed to myself never to repeat those mistakes. And I still to this day 5+ years later remember those misses. If I knew there was a built-in safety net with someone over-reading my cases, there would be less of sense of urgency and I doubt those mistakes would stick with me.

 

[gwooooooooooooooooooood]

It is incredibly program specific, and you're only going to get the real information from residents. Some programs residents said you have to fight for volume, and this is a red flag. But some programs residents mention they still have enough volume to go around to the point attendings help clear the list.

So it's a trade off. You need volume and pressure to train, but on the other had fellows are a great backup/teaching asset and having a home institution fellowship usually makes your life easier when it comes time to get a fellowship.