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my friend claims higher ranked residencies within a specialty provide better training, I told him no they were just academic so better research...what's the deal with this do top residencies actually make better docs?
 

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First of all, what is the definition of a "better doctor"?. All ACGME accredited residency programs should make "competent, safe doctors". It is extremely difficult to judge and compare the quality of training between different programs. The only measurement of training quality that everybody seems to agree on is the board passing rate, which I think that it does not give a precise qualitative measurement of training quality.

Than being said, I would give a general statement I just made is that top ranked programs will be more successful in making more competent doctors because during their selection process they were already looking for the self motivated individuals who need the necessary guidance to become good. But any hard-working self motivated student can be a good doctor even at lower ranked programs.

One big advantage of the higher ranked programs is that your career will be easy.. you will find a good fellowship at any place following by a good job in a good academic center.
 

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I am just an M1 but one thing that jumps to mind is volume and diversity of cases. At a big academic program you are more likely to be exposed to those complex cases than you would be at other programs. This doesn't necessarily correlate exactly with "ranking" but I think generally the big name programs are also the one that may see more of the complex cases which provide good diverse training that will prepare you for anything. And I think it also depends on how you define being a "good" doctor. Maybe you want to be really good at the bread and butter cases that will allow you to really serve a broad group of people in your community, or maybe you want to always be doing the most challenging cases that are generally referred to big centers. So the residency program that will train you the best might differ from person to person depending on what you want out of your training.
 
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I am just an M1 but one thing that jumps to mind is volume and diversity of cases. At a big academic program you are more likely to be exposed to those complex cases than you would be at other programs. This doesn't necessarily correlate exactly with "ranking" but I think generally the big name programs are also the one that may see more of the complex cases which provide good diverse training that will prepare you for anything. And I think it also depends on how you define being a "good" doctor. Maybe you want to be really good at the bread and butter cases that will allow you to really serve a broad group of people in your community, or maybe you want to always be doing the most challenging cases that are generally referred to big centers. So the residency program that will train you the best might differ from person to person depending on what you want out of your training.
You have to be careful though too because volume and complexity can also mean tons of fellows scooping cases.

Ideal setup is big volume and complexity with few fellows.
 

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You have to be careful though too because volume and complexity can also mean tons of fellows scooping cases.

Ideal setup is big volume and complexity with few fellows.
Not universally true. I trained at a place with all the fellowships in my specialty. All that meant was as opposed to an attending/resident pair scrubbing cases, a fellow/resident pair scrubbed, each doing their half, while the attending watched. Now I'm at a program with no fellows, and the residents still scrub, but largely watch/retract/cut suture while the attending does the entire case. Also, because there are no fellows, the volume that each subspecialty service can realistically handle is a lot less than it was at my program. I cannot say that my residents are getting a better subspecialty experience than I did because of the lack of fellows- I'd argue it's worse.
 

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Not universally true. I trained at a place with all the fellowships in my specialty. All that meant was as opposed to an attending/resident pair scrubbing cases, a fellow/resident pair scrubbed, each doing their half, while the attending watched. Now I'm at a program with no fellows, and the residents still scrub, but largely watch/retract/cut suture while the attending does the entire case. Also, because there are no fellows, the volume that each subspecialty service can realistically handle is a lot less than it was at my program. I cannot say that my residents are getting a better subspecialty experience than I did because of the lack of fellows- I'd argue it's worse.
I'd argue you're an exception to the rule though. I've been to 4 different training programs within my specialty, and at every institution the fellows detracted significantly from resident education. Without a doubt. They uniformly hog cases and have autonomy that should be granted to chief/senior residents instead. At least in orthopaedic surgery, don't go to a program with a bunch of fellows unless you're comfortable watching other people steal your cases as a chief resident. On the other hand, it sure is nice being a fellow at these hospitals...
 
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I'd argue you're an exception to the rule though. I've been to 4 different training programs within my specialty, and at every institution the fellows detracted significantly from resident education. Without a doubt. They uniformly hog cases and have autonomy that should be granted to chief/senior residents instead. At least in orthopaedic surgery, don't go to a program with a bunch of fellows unless you're comfortable watching other people steal your cases as a chief resident. On the other hand, it sure is nice being a fellow at these hospitals...
As a senior resident with zero interest in subspecialty practice, I was still doing my half of cases such as radical hysterectomies and lymph node dissections on Oncology and vaginal vault suspensions on Urogyn. Meanwhile, my residents rarely even see those cases (and when they do, they are retracting) because of the massive difference in volume. Lack of fellows and the additional surgical volume that fellow clinic brings in probably isn't the only cause of that, but I bet it's significant.

There was also the mentality that those super specialized cases weren't ours to "steal" in the first place- we weren't expected to come out of residency able to independently perform those cases. Learning how to do those is what fellowship is for. Now, if you have fellows taking away resident-level cases (that is, something that someone without fellowship training should be able to do) that's a different story. That hasn't been the case at any ob/gyn program I've seen with fellows. So my point still stands- "avoid programs with fellows" isn't universally true. Maybe it depends on the specialty.
 

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I'd argue you're an exception to the rule though. I've been to 4 different training programs within my specialty, and at every institution the fellows detracted significantly from resident education. Without a doubt. They uniformly hog cases and have autonomy that should be granted to chief/senior residents instead. At least in orthopaedic surgery, don't go to a program with a bunch of fellows unless you're comfortable watching other people steal your cases as a chief resident. On the other hand, it sure is nice being a fellow at these hospitals...
Man having fellows steal cases is half the reason for the need for fellowship
 

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I am just an M1 but one thing that jumps to mind is volume and diversity of cases. At a big academic program you are more likely to be exposed to those complex cases than you would be at other programs. This doesn't necessarily correlate exactly with "ranking" but I think generally the big name programs are also the one that may see more of the complex cases which provide good diverse training that will prepare you for anything. And I think it also depends on how you define being a "good" doctor. Maybe you want to be really good at the bread and butter cases that will allow you to really serve a broad group of people in your community, or maybe you want to always be doing the most challenging cases that are generally referred to big centers. So the residency program that will train you the best might differ from person to person depending on what you want out of your training.
Volume of interesting patients is half the equation. Academic places see more zebras, community places do more bread and butter and may become technically more proficient. Working with some of the big shots in the field though is the other big benefit of a big name residency -- you learn more working with the guy who wrote the book than imply reading his book, and their name as your reference carries a ton of weight.
 
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As a senior resident with zero interest in subspecialty practice, I was still doing my half of cases such as radical hysterectomies and lymph node dissections on Oncology and vaginal vault suspensions on Urogyn. Meanwhile, my residents rarely even see those cases (and when they do, they are retracting) because of the massive difference in volume. Lack of fellows and the additional surgical volume that fellow clinic brings in probably isn't the only cause of that, but I bet it's significant.

There was also the mentality that those super specialized cases weren't ours to "steal" in the first place- we weren't expected to come out of residency able to independently perform those cases. Learning how to do those is what fellowship is for. Now, if you have fellows taking away resident-level cases (that is, something that someone without fellowship training should be able to do) that's a different story. That hasn't been the case at any ob/gyn program I've seen with fellows. So my point still stands- "avoid programs with fellows" isn't universally true. Maybe it depends on the specialty.
Where I am rotating the gyn onc fellows swoop in to do the node dissection aspects of the cases and then disappear again, I'd be fairly annoyed if I were a resident.
 

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As a senior resident with zero interest in subspecialty practice, I was still doing my half of cases such as radical hysterectomies and lymph node dissections on Oncology and vaginal vault suspensions on Urogyn. Meanwhile, my residents rarely even see those cases (and when they do, they are retracting) because of the massive difference in volume. Lack of fellows and the additional surgical volume that fellow clinic brings in probably isn't the only cause of that, but I bet it's significant.

There was also the mentality that those super specialized cases weren't ours to "steal" in the first place- we weren't expected to come out of residency able to independently perform those cases. Learning how to do those is what fellowship is for. Now, if you have fellows taking away resident-level cases (that is, something that someone without fellowship training should be able to do) that's a different story. That hasn't been the case at any ob/gyn program I've seen with fellows. So my point still stands- "avoid programs with fellows" isn't universally true. Maybe it depends on the specialty.
Sounds like you're situation was very specific to OB-GYN, though.

The mindset in ortho (or at least for myself and those I know in the field) is that there is no such thing as a fellow-level case. You get more reps and autonomy in certain cases as a fellow (pelvic trauma, tibia plateaus, arthroplasty revision...), but you should still be prepared to do the case from skin-to-skin as a chief resident, no exceptions. If you're at a solid and well-balanced program, there should be enough volume in these areas to prepare you adequately to do so. At programs with a large amount of fellows, you might have a bit more volume, but you might as well be watching the surgeries on youtube. Maybe it's just an ortho thing, but I'd strongly advise against fellow-heavy programs, and anyone telling you otherwise in this field is selling you snake oil...
 
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Man having fellows steal cases is half the reason for the need for fellowship
Yep. It's a huge problem in surgical training in the modern era. If you're going into a surgical specialty, especially in ortho, be very suspicious of the "top ranked" programs. Talk to your mentors, especially if you know any fellowship directors... they'll know where the best fellows come from, and you might be surprised by the places they name.
 
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Sounds like you're situation was very specific to OB-GYN, though.

The mindset in ortho (or at least for myself and those I know in the field) is that there is no such thing as a fellow-level case. You get more reps and autonomy in certain cases as a fellow (pelvic trauma, tibia plateaus, arthroplasty revision...), but you should still be prepared to do the case from skin-to-skin as a chief resident, no exceptions. If you're at a solid and well-balanced program, there should be enough volume in these areas to prepare you adequately to do so. At programs with a large amount of fellows, you might have a bit more volume, but you might as well be watching the surgeries on youtube. Maybe it's just an ortho thing, but I'd strongly advise against fellow-heavy programs, and anyone telling you otherwise in this field is selling you snake oil...
Yeah, it's a different world in ob/gyn. Most of our fellowships (MFM, Urogyn, Onc, REI) are 3 years of subspecialty-specific procedures that graduating residents don't need to be able to do independently when they go out into generalist practice. It seems your experience with fellows is that they are taking away the routine cases that residents would otherwise do. That strikes me as strange- if gyn fellows were doing routine hysterectomies, that'd definitely be a problem. But while I'm bummed that most of my residents won't ever see something like a pelvic exenteration, it's not an expectation that anyone but a fellowship-trained gyn oncologist be able to do that skin to skin. That's what I meant when I said that when I was a resident, those cases weren't mine to be stolen.

In summary, different specialties are different.
 

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Yeah, it's a different world in ob/gyn. Most of our fellowships (MFM, Urogyn, Onc, REI) are 3 years of subspecialty-specific procedures that graduating residents don't need to be able to do independently when they go out into generalist practice. It seems your experience with fellows is that they are taking away the routine cases that residents would otherwise do. That strikes me as strange- if gyn fellows were doing routine hysterectomies, that'd definitely be a problem. But while I'm bummed that most of my residents won't ever see something like a pelvic exenteration, it's not an expectation that anyone but a fellowship-trained gyn oncologist be able to do that skin to skin. That's what I meant when I said that when I was a resident, those cases weren't mine to be stolen.

In summary, different specialties are different.
Sounds like it's not as much of a problem with well delineated subspecialties.

In Rads for example fellows either cherry pick the list of all the advanced imaging studies or scoop the good procedures.

While fellowship is now de facto required for a job, there are very few things outside of IR that a generalist wouldn't or couldn't do with sufficient cases/training.
 
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At my program, most of the fellows are welcome. The bulk of them are in specialties where there are more than enough cases to go around, or specialties requiring a heavy hours/service commitment where the extra help and expertise is a boon (trauma/CC).

The transplant fellows run the service and work their butts off. The only cases I guess they "steal" are liver transplants...but I don't really expect to come out of my general surgery training proficient in liver transplantation. The fellows are comfortable taking us through procurements, kidneys, and access cases, so there is no case stealing and they are fun to work with.

The peds surg fellows I guess steal cases, but I'm sort of resigned to it. The plus side of course to this means we have a peds surg fellowship and a lot of faculty who do active research - so if anyone is interested in matching in peds surg this is a great program to be at. And again, I don't really expect to be proficient at CDH and TEF repairs as a graduating general surgeon.

The only field where there are ever any issues is vascular, and I think if you take a step back and look at the situation objectively, those issues are as much the fault of us (the general surgery residents) as they are the vascular folks. Many of my classmates want to swoop in and do all the "cool" cases (open AAAs, CEAs, etc), but have zero interest in scrubbing in on endovascular cases. So they are basically saying they don't care to learn about >50% of the field but want to do the most complex of the cases anyways. I think vascular is becoming more distinct from general surgery anyway, so I suspect a lot of programs are the same.

So to sum up this aimless ramble - not all fellows are bad. Sometimes having fellows is just the consequence of having tons of volume. It's different at every program and in every field.
 

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In derm, many of the larger programs with Mohs fellows will have several attendings, and the fellows only work with specific attendings in the department, leaving the cases of the other faculty members to the residents. Also, not an insignificant number of procedural fellowships are hosted by private practice groups, so there is no issue of having to compete with residents.

Selecting a residency program is complicated: it's not only about the quality of the faculty and research, it is also about the volume and diversity of patients, as well as how well you fit into the program. Fit is huge, and unfortunately, generic rankings cannot predict which programs individuals will be successful at. At least in derm, higher-volume does not mean better training. If you see bread and butter cases over and over, you're knowledge base will not be as broad as someone who sees fewer patients but has a better mix of complex cases in addition to the standard stuff.
 
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Okay...so top ranked places don't generally make better doctors all residencies should be making good doctors? Better doctors means more technically competent, more clinically competent, more knowledgeable, more experienced, etc.
 

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Okay...so top ranked places don't generally make better doctors all residencies should be making good doctors? Better doctors means more technically competent, more clinically competent, more knowledgeable, more experienced, etc.
No, some programs are definitely better than others, but among the top 20-40 programs in a field, the differences aren't as great. For example JHU and MGH may be two of top five are so IM programs, but OHSU or UAB will still provide incredible training even if neither has the cachet of the former programs.
 

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Volume of interesting patients is half the equation. Academic places see more zebras, community places do more bread and butter and may become technically more proficient. Working with some of the big shots in the field though is the other big benefit of a big name residency -- you learn more working with the guy who wrote the book than imply reading his book, and their name as your reference carries a ton of weight.
I always see this written and I wonder why about the zebra thing. Like is it that the ivory tower just has more subspecialists or what? I remember a doc here wrote " If I need a hole in my head, send me to ivory tower"

I guess I just don't understand why the ivory tower would be better at the zebras. Is it just more exposure and practice with zebras compared to bread and butter? This seems like a basic question but I don't really understand why that is the status quo. And so that would mean that docs at ivory towers would be expected to be worse at bread and butter since they do less of it? It just seems conflicting because I never hear anyone say " don't go to ivory tower for your bread and butter" yet it's not like they have more hours in the day than other docs to become superior at zebras while still maintaining same proficiency for bread and butter.
 

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I always see this written and I wonder why about the zebra thing. Like is it that the ivory tower just has more subspecialists or what? I remember a doc here wrote " If I need a hole in my head, send me to ivory tower"

I guess I just don't understand why the ivory tower would be better at the zebras. Is it just more exposure and practice with zebras compared to bread and butter? This seems like a basic question but I don't really understand why that is the status quo. And so that would mean that docs at ivory towers would be expected to be worse at bread and butter since they do less of it? It just seems conflicting because I never hear anyone say " don't go to ivory tower for your bread and butter" yet it's not like they have more hours in the day than other docs to become superior at zebras while still maintaining same proficiency for bread and butter.
The zebras come to them so they see it more. It's not like you need to see acute pancreatitis a million times to know how to treat it
 
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I always see this written and I wonder why about the zebra thing. Like is it that the ivory tower just has more subspecialists or what? I remember a doc here wrote " If I need a hole in my head, send me to ivory tower"

I guess I just don't understand why the ivory tower would be better at the zebras. Is it just more exposure and practice with zebras compared to bread and butter? This seems like a basic question but I don't really understand why that is the status quo. And so that would mean that docs at ivory towers would be expected to be worse at bread and butter since they do less of it? It just seems conflicting because I never hear anyone say " don't go to ivory tower for your bread and butter" yet it's not like they have more hours in the day than other docs to become superior at zebras while still maintaining same proficiency for bread and butter.
Certain Ivory towers are just zebra magnets. Take cystic fibrosis for example. Your average community hospital will have cystic fibrosis patients come through every now and again, but Ivory Tower university probably has a Cystic Fibrosis center that treats patients from cradle to grave. Training there, you'll have seen every manifestation of cystic fibrosis known to man.

Does that help you if you want to practice in Anytown, USA? Maybe. Maybe not. Totally depends on your goals and interests (an annoying answer, but its true I think).
 

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There's no "ranking"... just reputation.

and it matters.
 
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Wait, so do we agree that ivory tower docs/residents are probably more specialized so they arent as technically proficient in bread and butter cases as the community program docs/residents. That was honestly my main point when arguing with my friend. That at the ivory tower they are doing more research/advanced cases so less time for basic stuff compared to the community guys who can only do the bread and butter so do it all the time.
 

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Wait, so do we agree that ivory tower docs/residents are probably more specialized so they arent as technically proficient in bread and butter cases as the community program docs/residents. That was honestly my main point when arguing with my friend. That at the ivory tower they are doing more research/advanced cases so less time for basic stuff compared to the community guys who can only do the bread and butter so do it all the time.
I'd say you're incorrect on that. The two things aren't mutually exclusive as you seem to believe. Usually the places that get super rare pathology are high-volume overall, so trainees get a lot of bread-and-butter experience as well. It's not as if being a Rare Disease Center means that nothing but Rare Disease comes through.
 

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Generally, "prestigious" residency programs produce better clinicians because the med students who match at these programs are intelligent, dedicated and self-driven. Medical training is what you make of it; you can graduate residency by doing the bare minimum, and you'll be a crappy doctor.
 
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I'd say you're incorrect on that. The two things aren't mutually exclusive as you seem to believe. Usually the places that get super rare pathology are high-volume overall, so trainees get a lot of bread-and-butter experience as well. It's not as if being a Rare Disease Center means that nothing but Rare Disease comes through.
Yeah I see what you're saying but I was thinking more along the lines of if a community doc does basic surgery X 100 times a year and ivory doc does it 25 times a year since he has so much other complicated stuff to do, even though ivory doc is still able to do surgery X he won't be as good at it. Maybe my scenario is flawed because it doesn't even mirror reality, not too sure.
 
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Generally, "prestigious" residency programs produce better clinicians because the med students who match at these programs are intelligent, dedicated and self-driven. Medical training is what you make of it; you can graduate residency by doing the bare minimum, and you'll be a crappy doctor.
Yeah I understand that, to me that's a confounding factor since I am more interested in which centers breed an environment that makes the best clinicians, best researchers, etc.
 

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Yeah I understand that, to me that's a confounding factor since I am more interested in which centers breed an environment that makes the best clinicians, best researchers, etc.
I cant say that the information I have is unbiased, but I think you also have to take into account that the top centers have a ton more resources as well as faculty. More faculty = more case volume, and residents learn more approaches to doing a case. More resources can mean a lot of things, one that comes to mind is having support staff that will take care of things like dispo (my medical school hospital had the residents doing social work stuff), nursing care, etc. I do understand your line of reasoning and it's something I hear from community surgeons all the time, though I find it dubious.
 

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Yeah I see what you're saying but I was thinking more along the lines of if a community doc does basic surgery X 100 times a year and ivory doc does it 25 times a year since he has so much other complicated stuff to do, even though ivory doc is still able to do surgery X he won't be as good at it. Maybe my scenario is flawed because it doesn't even mirror reality, not too sure.
Well I think the scenario is flawed because you're not talking about trainees anymore. You asked which programs provide better training. Comparing two different physicians out in practice doesn't get at that. Your Ivory Tower doctor doesn't NEED to be great at the basic procedure because he is at the point where his career is built upon doing the more specialized procedures.

A resident at Ivory Tower, on the other hand, is still learning. That resident will be doing a variety of rotations, getting exposure to both bread-and-butter and specialized cases. If residents were only doing the rare cases, you could argue that their training was inferior. But that has never been the case at any training environment I've seen.
 
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If the trainee at the community program doesn't get to do any specialized cases then isn't he doing more basic cases then the trainee doing both at the ivory tower
 

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If the trainee at the community program doesn't get to do any specialized cases then isn't he doing more basic cases then the trainee doing both at the ivory tower
Not necessarily, no. You seem to be thinking that there's a set number of cases that everybody gets no matter where they are:
Community program has 100 cases a year. All are basic.
Ivory tower program has 100 cases a year. 50 are specialized, so only 50 are basic.

Result: more experience with specialized cases, causing less experience with basic cases.

That's the wrong way to think about it. There are minimums that all programs are expected to reach, but above that it can be extremely variable. So being at the ivory tower doesn't necessarily mean you specialized cases instead of basic cases. It may mean that you're doing more specialized cases as well as more basic cases:
Community program has 100 cases a year. All are basic.
Ivory tower program has 300 cases a year. 100 are specialized, 200 are basic.

Result: more experience with both specialized and basic cases.

Does that make sense??

Of course this is an extremely simplified and exaggerated example, but I'm trying to help you understand that you're starting off with a misconception of how it works.
 
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Not necessarily, no. You seem to be thinking that there's a set number of cases that everybody gets no matter where they are:
Community program has 100 cases a year. All are basic.
Ivory tower program has 100 cases a year. 50 are specialized, so only 50 are basic.

Result: more experience with specialized cases, causing less experience with basic cases.

That's the wrong way to think about it. There are minimums that all programs are expected to reach, but above that it can be extremely variable. So being at the ivory tower doesn't necessarily mean you specialized cases instead of basic cases. It may mean that you're doing more specialized cases as well as more basic cases:
Community program has 100 cases a year. All are basic.
Ivory tower program has 300 cases a year. 100 are specialized, 200 are basic.

Result: more experience with both specialized and basic cases.

Does that make sense??

Of course this is an extremely simplified and exaggerated example, but I'm trying to help you understand that you're starting off with a misconception of how it works.
that makes no sense. are the residents just twiddling their thumbs at these community programs? everyone has the same hours in a day and I don't think there are many residents sitting around waiting for cases to show up.

you can't have it both ways. either the ivory tower is better at zebras and loses some technical prowess with bread and butter, or academic surgeons are similar to community ones.
 

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that makes no sense. are the residents just twiddling their thumbs at these community programs? everyone has the same hours in a day and I don't think there are many residents sitting around waiting for cases to show up.

you can't have it both ways. either the ivory tower is better at zebras and loses some technical prowess with bread and butter, or academic surgeons are similar to community ones.
If anybody who does General Surgery wants to weigh in, I'll defer to them. But the subject of the thread was originally residencies in general, so I'll describe my experience in ob/gyn.

I've worked at a program where the residents just barely met minimum surgical numbers each year. Because numbers were low, it was a smaller program, so they worked very hard in the OR and covering required services. They weren't twiddling their thumbs by any means, but they graduated with minimum numbers and never saw some zebras of the field. In contrast, I've worked at a high-volume program where the residents blew past most minimums as second years- and then continued to build up more numbers over the next two years. They graduated with much more technical experience overall, in all kinds cases. So you are arguing that coming out of program A with the minimum required numbers of basic procedures is better than coming out of program B with three times the minimum of basic procedures plus experience with "zebras?"

This is getting away from "community" vs. "ivory tower" and more into "low-volume" vs. "high-volume." But in my field, the two often go together.
 

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that makes no sense. are the residents just twiddling their thumbs at these community programs? everyone has the same hours in a day and I don't think there are many residents sitting around waiting for cases to show up.

you can't have it both ways. either the ivory tower is better at zebras and loses some technical prowess with bread and butter, or academic surgeons are similar to community ones.
Completely agree with 22031. # of cases done varies pretty heavily between programs. At some of the lower volume places you'll see residents double scrubbed and ****, or leaving before 6 on OR days. Good lifestyle, poor training. To give an example, the avg # of cases for ENT in a graduating resident is ~1700. However, you'll see some programs with 3000 as their average. Even accounting for some confounding factors (more peds cases, breaking down cases into components, etc), it's obvious that the case load is not the same between programs.
 
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that makes no sense. are the residents just twiddling their thumbs at these community programs? everyone has the same hours in a day and I don't think there are many residents sitting around waiting for cases to show up.

you can't have it both ways. either the ivory tower is better at zebras and loses some technical prowess with bread and butter, or academic surgeons are similar to community ones.
Do you think that all hospitals are covering the same amount of cases? They're all uniform in what comes through the doors and how many cases they do per day?
 

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Completely agree with 22031. # of cases done varies pretty heavily between programs. At some of the lower volume places you'll see residents double scrubbed and ****, or leaving before 6 on OR days. Good lifestyle, poor training. To give an example, the avg # of cases for ENT in a graduating resident is ~1700. However, you'll see some programs with 3000 as their average. Even accounting for some confounding factors (more peds cases, breaking down cases into components, etc), it's obvious that the case load is not the same between programs.
interesting
 
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Merely

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That makes a lot of sense, thanks for taking your time to explain that to us less experienced folks.
 

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I think the consensus among practice members I know is that some of the community grads are better technically than their ivy tower brethren. They are more plug and play because they have been doing bread and butter stuff starting as early as intern year, without fighting with fellows for cases. But they don't know the zebras well -- never saw them. The ivy tower guys have done a fair amount of hands on stuff for sure, but (a) have dealt with more zebras while the community guys were cranking out routine things so the volumes are necessarily very different, (b) worked under more fellows which in my experience is more often a curse than a blessing, but certainly with exceptions, and (c) were likely at programs where the earlier years were heavier with floor work than at some of the community places, which tend to be much leaner. So yes they absolutely come out of their respective residency programs with different strengths and skill sets. It's naive to think the ivy tower is guy covers more ground rather than different ground, and it's wrong to say one is "better" trained, they both have some deficits. It's really akin to signing an infielder who fields great but can't hit so well versus an infielder with a hot bat but can't field so well. Either way an employer will have a lot to teach his new employee and it comes down to what he prefers to teach (hitting or fielding/zebras or technical skills). The academic employers will prefer those short on the latter (ie those that already know their zebras) and the community shops which crank out routine stuff the former (ie those with the refined technical skills) but either group will have a bit of a steep learning curve when they get out. That's just life. Neither is better trained and both will have years of learning ahead. And in most cases both groups end up pretty well trained by a few years out of residency -- the path chosen won't dictate how good a doctor you are going to be, but it might dictate the kind of practice you'll gravitate to.
 
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Really, the "which type of program is better" question isn't one you can answer before you even know what you're going into or what you think your ultimate goals may be. Once you've made some decisions in that regard, you can get better advice that will apply to your own situation.