You can see (do) a lot of procedures as a fourth year if you are "proactive" i.e. if you want to, it is basically see one, do one and then teach one. Putting in an IJ or Sub-clavian is something that a midlevel resident at least needs to be able to do, and I'm sure you would get the opportunity to do it, but after you have done 3 or 4 I would think that you've gone pretty far up the learning curve with this procedure, there is A LOT more to medicine than this, and although it sounds cool to be confident with this procedure, everyone learns how to do it by the end of residency, so I wouldn't based a decision on a residency program on this. . . i.e. I wouldn't expect to find a chief resident or final year resident complaining about not having done enough central lines at most (all?) programs. . . a lot of programs have checklists for procedures, i.e. a certain amount you have to do. While putting in a central line may seem like a highly specialized sought out skill, it is not, and something you can learn anywhere . . . You could come into the hospital on your day off as a resident, sit in the ICU and just ask to do all the central lines or whatever going on that day, . . or just look for opportunities during your residency, maybe it takes on average 15 minutes to put one in so if after three years you haven't done more than 2 then yes it is your fault for not being "proactive", but this isn't like surgery where if you do two times as many colectomies you really are more competent, I doubt there is a difference between doing 40 and 80 central lines in terms of being a good internist as most internists don't do these procedures regularly as they are done on inpatients and so easy to do that residents teach residents how to do them (i.e. no big deal) . . . people will be more impressed if you know the latest treatment and management of diabetes than if you said you made sure you did 80 instead of 40 central lines during residency, . . . again if it takes you at most 30 minutes per central line to prep and read cxr later that is only 40 hrs of your life during residency . . . (I'm a fourth year and I can put in a subclavian, IJ, a-line, peripheral line (some students can't even get a peripheral iv so I list it) . . . but I am not deluded to think that I am "competent" in terms of managing an icu patient yet, . . . doing these procedures is like learning to tie your shoes, managing patients is like getting a license to drive.
ICU teaches you a lot, but you really focus just on critical problems in the ICU i.e. keeping the patient alive, not "let's figure out if our patient has SLE or some other connective disease disorder" . . . there is an art to general IM ward medicine, i.e. consulting and planning management of these patients which have different focus of the clinical management, for a resident to say that handling ICU patients makes general medicine wards easy I think more reflects perhaps the amount of work involved in one icu patient versus one general medicine patient, . . . but obviously different skills are needed on the wards than in the icu. . . although a general medicine wards patient will survive your care, there are other things you need to address like treatment of chronic diseases, outpatient planning, consulting, and sometimes just trying to diagnose which for some medicine patients is hard even for attendings, i.e. I have seen many "straight-forward" ICU patients i.e. sepsis, ards, etc . . . which appear less complex than say an inpatient with a dozen chronic diseases and undefined hematologic problems who actually needs more evaluation and workup while the ICU patient just needs monitoring more frequently but the management is more or less a closed case.
I think that residents who do best are the ones who ask "What is the big picture of what is happening with my patient?" and then they are able to come up with a coherent plan and fill in the details, instead of just being an intern their whole residency i.e. treating lab values like low hgb and not appreciating how each patient's medical problems are unique or why certain management decisions are made. I think the worst residents complain why some attending did this or that to their patient, complain that it doesn't make sense, and then don't try to figure out why the patient was managed that way. Obviously, medicine requires a lot of reading, so part of being good is reading up on your patients and going to conference.
I wouldn't go to a "Frontloaded" program unless you can do a large number of patients efficiently, I took huge numbers of patients as a sub-I and on other electives so that I can deal with a dozen patients and know what is happening with all of them, a lot of medicine is pattern recognition so seeing how a lot of patients are managed is good this way, if you haven't done this then maybe go to an easier program I guess, it doesn't seem to matter as work expands to fill the available time whether you have a dozen patients or 6 . . .
