Scared MS3... please help me out...

[LurkNoMore]

This is very similar to a post I put up on the anesthesia board, but I didn't get too many responses and I feel here I may get a bit more feeback (I hope)....

I'm an MS3 that after doingPeds/Med/Surg/OB can't really see myself doing these professions (for various reasons). Going in to MS3 year I sought to have an open mind, considering things such as Medicine (possibly subspecialty), Anesthesia, and seeing if I enjoyed surgery enough to commit to its rigors. I did a 3 week selective early on in my 3rd year in Anesthesia, expecting to love every minute of it, which I didn't, although not a true dislike either. I'm on F-Med right now and I will be taking call this friday night with the anesthesia residents to get a bit more exposure. I will need to decide soon what rotations to do as a 4th year, can any of you out there relate to a significant portion of my story and/or lend advice on how to find my way through my mess? Thanks again for reading, and for your thoughts, feel free to ask for clarifications, etc.

 

[Uncle Izzy]

The thing I think you need to figure out is to identify the things you liked and disliked about each rotation you did.

Did you not like surgery because of the hours? Or was it the approach to solving problems?

OB/GYN- Did you dislike the patient population, the problems presented, the approach?

Anesthesia- Did you dislike the physiology? The pharm? The people?

ETC ETC ETC.

Once you can really tease out the factors that make you happy and the ones that drive you crazy, then you can better request help on deciding a specialty.

I recall there is a program from the AAMC that allows you to enter information about yourself and then it suggests specialties that may work for you. I dont have the link but someone in this forum definitely does.

Just my $0.02.

 

[LurkNoMore]

Thanks Izzy, (a good 2 cents)
When I use your approach I guess I sell myself on anesthesia

Surgery: Hated the hours, and disliked a few of the personalities, didn't dislike the problem solving or the hands-on, quick "solution" (was actually impressed/intimidated with the speed and the definitiveness with which sounds medical decisions were made)

OB- delivering babies scared the @#$^ out of me, didn't like the professional environment (some of the residents/nurses)

Anesthesia- liked the pharm, physio, people were pretty good (some were cooler than others of course), didn't like the charting and the feeling of disorientation relating to all the lines and such running from the pt to various drips/the machine (experience might cure), also felt incredibly vulnerable starting an IV (experience again...)

Peds/IM- the actual medicine part was ok (figuring out what was wrong, what labs to order, etc. ...), all of the paperwork, placement, disposition, we can't do this b/c of <insert reason here that isn't due to medical risk>, and admitting patients (esp in the middle of the night) got to me pretty quickly (especially on IM)

I just don't want to be missing the boat on something else I should be considering, since I didn't anesthesia from my first day on the other side of the surgical drape!!

 

[OncoCaP]

Do you do a psych rotation?

 

[LurkNoMore]

Yes, I'm on family now (for 4 more weeks) then 3 wks of rad onc (selective) and 3 weeks of Ortho surg (selective), then 6 wks of psych, you think I might like psych? (I'm open to anything at this point since my list of "I might do this" has been slashed since starting MS3).

 

[andros]

Have you thought about something like radiology, rad onc, or pathology? What about PM&R or a medical subspecialty? I wasn't a huge fan of IM for some of the same reasons as you, but maybe you could suffer through the residency and do a medical subspecialty that doesn't have as much of the social work aspects to it.

Good luck with your decisions... it's tough to figure out what to do, but it's also good to be able to rule stuff out.

 

[Uncle Izzy]

Thanks Izzy, (a good 2 cents)
When I use your approach I guess I sell myself on anesthesia

Surgery: Hated the hours, and disliked a few of the personalities, didn't dislike the problem solving or the hands-on, quick "solution" (was actually impressed/intimidated with the speed and the definitiveness with which sounds medical decisions were made)

OB- delivering babies scared the @#$^ out of me, didn't like the professional environment (some of the residents/nurses)

Anesthesia- liked the pharm, physio, people were pretty good (some were cooler than others of course), didn't like the charting and the feeling of disorientation relating to all the lines and such running from the pt to various drips/the machine (experience might cure), also felt incredibly vulnerable starting an IV (experience again...)

Peds/IM- the actual medicine part was ok (figuring out what was wrong, what labs to order, etc. ...), all of the paperwork, placement, disposition, we can't do this b/c of <insert reason here that isn't due to medical risk>, and admitting patients (esp in the middle of the night) got to me pretty quickly (especially on IM)

I just don't want to be missing the boat on something else I should be considering, since I didn't anesthesia from my first day on the other side of the surgical drape!!

Well , Anesthesia sounds like something you liked. Be sre to listen to your gut feeling. Also, I say definitely look into Emergency Med. It has the medicine work ups at a pace that is basically IM on steriods and also has the freedom you get on anesthesia as far as scheduling, etc.. Also, the fast pace you liked in surgery is definitely applicable.

Alot of the things you said you are scared of will definitely come with more experience. I promise you that after putting in some A lines, IVs, and central lines you will feel inifinitely more comfortable.

One thing to note about anesthesia that you said you didnt like was the charting. Many many places are moving to electronic anesthesia records and I think this will become the standard of care and also makes the anesthesiologist's life infinitely easier. Besides, if electronic records doesnt take off, you can choose a career where you supervise CRNAs and that means they have to do all of the charting. Dont let those little things be the deciding factor.

As far as surgery goes, you may want to look into urology. It has all of the swift decision making and the other perks of surgery but the hours are inifinitely better and although it's hard to generalize, urologists tend to be pretty laid back and not royal pricks like alot of gen surgeons. Plus, call is always home call and the only true urologic emergency besides surgical complications is testicular torsion. (this is my shameless plug... I just matched in urology... Woohoo!)

Glad I could help.

 

[ericdamiansean]

Well , Anesthesia sounds like something you liked. Be sre to listen to your gut feeling. Also, I say definitely look into Emergency Med. It has the medicine work ups at a pace that is basically IM on steriods and also has the freedom you get on anesthesia as far as scheduling, etc.. Also, the fast pace you liked in surgery is definitely applicable.

Alot of the things you said you are scared of will definitely come with more experience. I promise you that after putting in some A lines, IVs, and central lines you will feel inifinitely more comfortable.

One thing to note about anesthesia that you said you didnt like was the charting. Many many places are moving to electronic anesthesia records and I think this will become the standard of care and also makes the anesthesiologist's life infinitely easier. Besides, if electronic records doesnt take off, you can choose a career where you supervise CRNAs and that means they have to do all of the charting. Dont let those little things be the deciding factor.

Yup, sounds like Anes is the way for you, though you would probably should try it out as an elective in another hospital to gauge whether an environment change might actually make you like it even more.

I know some ppl who absolutely hated some of their rotations due to various factors ie. the environment, the consultants, the nurses etc but are actually into that specialty now when those factors were changed.

Experience will give you confidence, and count yourself lucky as I'm sure there are heaps of medical students out there who have not done a single procedure including venepunctures.

I don't think anyone likes charting, neither do I esp with my horrendous squiggly writing , but that saves everyone's a** from being sued

 

[LurkNoMore]

Call went pretty well last night, it was a slow friday night, just an intubation in the CTICU, a hypoxic dude in the PACU and an MJ/Coke/EtOH dude with a stab wound to the belly (Aline, IJ, some bicarb and to the SICU after 2.5 hours in the OR). I didn't do any procedures, just helped draw up drugs, refill the code back, set up rooms, etc. Overall I enjoyed being with the residents, I remembered more anesthesia than I thought I would after 5+ months doing other stuff. It was helped by the fact that I already kinda knew the chief, and she already has a sweet job lined up back in her home town so she is really excited, the CA-2 I was working with was also really chill and they had a chance to spend a lot of time talking to me about +/- and their reasons for choosing Anesthesia. They did tell me I should look at other stuff [rads...] early on 4th year and to do an anesthesia away rotation, they were very excited that I had taken the time to come hang with them (they did finally talk me into cutting out at about 230 a.m. when they were going to crash since a CRNA was taking the next case unless it was a mess). I guess you could say I'm not married to anesthesia just yet, but we are definitely dating now ! Yous guys have any thoughts on what else I should take a peek at early (I guess rads.... what else.... path?? derm?? "x"??).

 

[excalibur]

Hey Lurk,

I posted some stuff on the anesthesia forum when you posted.

Derm/Rads: If you have the board scores definitely check this out. I didn't have the scores, so I knew this was not going to happen for me.

EM: Many anesthesia guys also considered this as well. I didn't like that there is still some bs patients you have to deal with (drunks, druggies) and just other things really. It just wasn't for me, but I thought it might have been.

Path: Considered it. Never did a rotation. Much like rads, you're a diagnostician. Slides and tissue samples instead of films. No intern year of medicine (but you can't base your career on this perk...tempting though). 8-5 type hours. Pay similar to anesthesiology. Bottom line for me is that I couldn't deal with not seeing patients. That's what I went into medicine for. I realized while in med school that patients can quickly become a pain in the arse, so I wanted limited interaction with them. I still wanted to see patients but not in the chronic management sense. Anesthesia gave me that.

Psych: The patient population killed this one for me. From the outside psych can seem fascinating, but when I had to deal with the patients with these disorders, it was a real burden. You are going to deal with A LOT of depressed patients, and guess what...it's depressing. You deal with suicidal patients, patients who have lost everything to addiction, and of course psychotics. You may think that these people are the ones who need help the most, and I agree. I just couldn't see myself dealing with schizophrenics or patients who were constantly down in the dumps and remaining sane myself.

Neuro: Pretty cool for me. Pretty interesting. I just want more hands on, more procedures. No real complaints.

Anesthesiology: Some comments. It's very tough to appreciate the aspects of anesthesia during a student elective. All the residents say, it's a totally different ballgame when you're left alone to take care of the patient. So do more talking with the residents to get a sense, and read some of the posts/threads on the anesthesia forum on SDN. One thing you'll have to be comfortable with in anesthesiology is that you'll be serving as "the offensive lineman". You know you're providing a great service and when you're doing a great job, but rarely does anyone else recognize it. People recognize you mostly when things are going wrong. Basically, not a lot of praise, prestige, or admiration comes with the job, and that's something you have to be OK with.

Before anyone jumps down my throat about what I thought about the specialties. Remember these were just how I felt when I went through them. I feel that every specialty in medicine is an extremely valuable asset in health care, and I don't think for one second that one specialty is superior to the other. I understand that every med student is different, and what's gold for one student is crap to the other. The OP has expressed several feelings that I felt during third year, and that's why I just wanted to express what I felt in the other specialties that he/she has yet to explore.

 

[LurkNoMore]

Ex,
I didnt see your posts on gasforums... I have read a good bit on there, although most of it has just scared me (CRNA's, etc.). You are right about being an offensive lineman, but I really could care less about getting daily recognition and praise, I would rather enjoy what I'm doing, know when I am going to be done, be able to see my family, be able to sleep regularly and have a comfortable income (I'm not talking crazy money... just comfortable). I think I'm a very competitive applicant, and I fancy that I could look at derm, the only thought I have against doing this is that I would be getting a late start on actually pursuing derm if I did wind up kinda liking it. So in light of this.... maybe I should not look at it and glance at path and rads (in other words, do an ANES away in July, rads and path in aug and september....). I will do an EM rotation, but prob not early, as I feel that my feelings would be exactly as yours are relating to the BS you'd deal with most of the time. In the end I think I am a lot like you, I think just a touch of patient contact would be enough for me...

 

[excalibur]

With that lineup of anesthesia, rads, and path during july/aug/sep, I'm sure you'll figure it out. Good luck! Any other questions, just pm me.

 

[nutcancer]

lurk, just admit it. you want to make the 300k and work from 6:45 to 3:00, call q7 days, read a book and recline while the surgeon works like a dog, and the potential to double your income as a pain doc.

seriously now, don't get all touchy feely about why you want to do anesthesia. LOL!

 

[Mista Suprane]

read a book and recline while the surgeon works like a dog

clearly made by someone who has no clue what an anesthesiologist actually does. read this.

http://forums.studentdoctor.net/showthread.php?t=348025

sure the hours/pay are pretty good. i'll be the first to admit that. but when they're working, they're WORKING.

 

[nutcancer]

clearly made by someone who has no clue what an anesthesiologist actually does. read this.

http://forums.studentdoctor.net/showthread.php?t=348025

sure the hours/pay are pretty good. i'll be the first to admit that. but when they're working, they're WORKING.

I've seen anesthesiologists in work. I stand by what I said. Relatively speaking, its not nearly as intense/tedious as what the surgeon's doing. You can go ahead and show people the other post where the anesthesiologist is clearly describing one of his more busier days. Face it, anesthesia is all about the hours and the pay. Comparatively speaking (to other fields), its one of the easier-to-perform/chill jobs out there.

And the railing begins.......

 

[Mista Suprane]

And the railing begins.......

i'm certainly not going to rail on you for anything; i'm a med student just like you, and have neither the experience nor status to flame you for anything. i just think you might be a little misinformed. and, fairly, i am a little biased.

Relatively speaking, its not nearly as intense/tedious as what the surgeon's doing.

i will be the first to agree with this, at least partially. however, i'm not really referring to the intensity, but rather the emergent nature of a lot of what an anesthesiologist does. lots of quick thinking/responses to limited information. hang out in a CABG/valve replacement, vascular surgery, craniotomy, trauma, or transplant and you'll see what i mean. most patients get at least one central line, a-line, pressors, fluid resuscitation, etc. who do you think is doing all that stuff, and managing hemodynamics of these volatile patients during a long surgery? it's like surgery in the ICU - these patients are sick. we are required to do 4 critical care months, most programs make you do 6 during your residency. i will concur that some of your surgical fields have similar demands(gsurg/ortho/neuro/trauma, maybe ENT/plastics). but uro/optho/onc/colorectal?

Comparatively speaking (to other fields), its one of the easier-to-perform/chill jobs out there.

compared to rads/derm/radonc/peds/hemeonc/rheum/endocrine/FP/IM/path/neuro/psych/uro/optho? um... no. probably similar to cards/CCM/GI/ER. i agree on gsurg/ortho/neuro/ENT/plastics.

you are certainly allowed to have whatever opinion you like, and this is a great message board simply because we are allowed to express any feeling we might have. but i don't want people to see your above post, and think that it is fact. the hours and pay are great, but it is CERTAINLY not one of the "easier-to-perform/chill jobs out there." anyone expecting that will probably find out the hard way. you have to be calm under pressure, which most anesthesiologists are (probably why it appeard to be chill to you). or perhaps you are referring to those cush surgicenter jobs, where most cases are non-complex. yes they exist, but they are more rare than you think.

to the OP: as someone said before, don't base your opinion on anesthesia just on what you experienced as a student. it's a lot different when you are in charge, even as a resident. other careers to consider: if you like the working with your hands aspect (lines/tubes/needles on a daily basis), consider ER. if you are fascinated with the physio/pharm, consider IM/critical care (you can also do CCM after anesthesia, and in fact, the majority of academic SICUs are closed units run by anesthesia trained CCM docs.)

i'd be a liar if i said hours/pay didn't influence my decision, but i did three anesthesia rotations, and i love it. make sure you choose something you like (or at least, what you hate the least), and don't fully base your decision on lifestyle (perceived or truthful) or pay, because nobody can predict what reimbursement will be like in the future.

 

[AlternateSome1]

It sounds like what you didn't like about anesthesia was being inexperienced, which is pretty intimidating for everyone doing pretty much anything. As far as having nothing jump out and grab you, remember that medicine is an occupation. Every job has some crap that you have to deal with. As long as you can be satisfied with what you are doing at the end of the day, at the end of the week...you'll be fine.

 

[beanbean]

I am biased because it is my chosen field, but I agree you check out EM. Positives: Fantastic and fun collegues, interesting procedures, diversity of clinical problems keeps things interesting, never knowing what will roll in next, shift work, ***check out EM forums for more
Negatives: Nights and weekends (but shift work info), sizable population of "difficult" patients, little continuity

I have know quite a few students who have narrowed their list to EM or Gas. They seem like vastly different fields, but seem to hold attraction for the same kind of people.

Good luck as you approach 4th year!

 

[nutcancer]

'however, i'm not really referring to the intensity, but rather the emergent nature of a lot of what an anesthesiologist does. lots of quick thinking/responses to limited information'

yeah yeah yeah, relax. i like anesthesiologists, very calm fun simple people. but listen, every field has their share of emergent cases that require quick thinking. in your post, i guess you have listed your reasons for being passionate about anesthesia. i can respect those. but like you said, the money/lifestyle plays a part in your decision. i'm here to challenge you that it makes A BIG HUGE part in your decision. i'd bet my left cancerous nut that if anesthesia paid pediatrician money and had cardiology hours, you would bail on your reisdency like there's no tomrrow

 

[excalibur]

I am biased because it is my chosen field, but I agree you check out EM. Positives: Fantastic and fun collegues, interesting procedures, diversity of clinical problems keeps things interesting, never knowing what will roll in next, shift work, ***check out EM forums for more
Negatives: Nights and weekends (but shift work info), sizable population of "difficult" patients, little continuity
I have know quite a few students who have narrowed their list to EM or Gas. They seem like vastly different fields, but seem to hold attraction for the same kind of people.

Good luck as you approach 4th year!

Yep. That's what killed EM for me.

 

[fakin' the funk]

lurk, just admit it. you want to make the 300k and work from 6:45 to 3:00, call q7 days, read a book and recline while the surgeon works like a dog, and the potential to double your income as a pain doc.

seriously now, don't get all touchy feely about why you want to do anesthesia. LOL!

Choosing a specialty isn't about being "tough"...at least for the OP.

 

[Mista Suprane]

i like anesthesiologists, very calm fun simple people.

I've seen anesthesiologists in work.

it is quite obvious that you a)haven't done a rotation in anesthesiology and b)are forming your impressions based on what you saw on the other side of the ether screen when you were bored retracting during your surgery rotation. perhaps you should allow those that know something valuable about a specific field talk about it. i'm sure you could talk quite intelligently about surgery or medicine, why don't you do that instead?

but listen, every field has their share of emergent cases that require quick thinking. in your post, i guess you have listed your reasons for being passionate about anesthesia.

the situations i mentioned are a daily occurence at a large academic hospital. there are very few specialties that can really compare with this emergence. unfortunatetly, your lack of experience with the field combined with some preconceived notions about it have made you unable/unwilling to understand this, and result in posts that haven't really been all that beneficial to the OP.

but like you said, the money/lifestyle plays a part in your decision. i'm here to challenge you that it makes A BIG HUGE part in your decision. i'd bet my left cancerous nut that if anesthesia paid pediatrician money and had cardiology hours, you would bail on your reisdency like there's no tomrrow

i don't think anyone would seriously consider such a residency as the one you described, mr. uniball. i'm not sure it exists; general surgery maybe? no, the way i decided was the way that most medical students do. find out what they like (in my case cardiology, surgery, and anesthesia), what they don't like (OB, rads, peds, FP), figure out what they are competitive for, and then factor in lifestyle and reimbursement. unless there is a deep seated passion for a particular specialty (which most medical students really don't have), this is the way it should be done. i surely couldn't do something i hated for 40 years, no matter how much it paid. the money/lifestyle honestly did play a huge part in deciding between anesthesia, cardiology, and surgery, but it could have never made me do rads.

btw, i hope you don't really have ball CA. if you do, i apologize for my comments.

 

[Hoo\/er]

You also need to keep in mind the fact that medicine may not be for you. Too many students are scared into thinking they have to find a specialty that they like. I completely understand where you're coming from, too. With the amount of time and effort you have invested thus far, not to mention the loans that are now looming over your head, it can get pretty scary.

I took the road less traveled, and decided to get out of medicine. I did finish school, though. I see myself much like you when I was in your place.

I can see why you may be drawn to Anesthesia. Everybody says how great the lifestyle is, and they do make good coin. If you look at the statistics, however, Anesthesiologists actually are on the high end of average hours worked. Take what you hear with a grain of salt.

The sad fact is that most students like myself aren't truly exposed to the nuts and bolts of the medical lifestyle until approximately halfway through their medical education. In other words, you are expected to "fall in love" with some random specialty at some point during your junior year. It sucks, but unfortunately there isn't much that can be done about it.

I guess the point that I'm trying to make is to not "force" yourself into a specialty. Sure, the debt and time wasted sucks. But believe me when I say those are minor points that can be overcome. Ultimately, your happiness 20 or 30 years down the road is where it's really going to matter. Do you want to wake up on your 50th birthday and realize you've been doing something that makes you miserable for the last 25 years because of a couple hundred thousand in debt? I didn't, and that's what brought me to the realization that I needed to get out when I did.

You know deep down whether or not you like something. If that something is totally unrelated to medicine, don't let people tell you that it's wrong. It is completely normal, and medicine isn't for everyone.

 

[nutcancer]

'i don't think anyone would seriously consider such a residency as the one you described, mr. uniball.'

hey, if you were really passionate about anesthesia, you would go into it even under those hypothetical circumstances. i agree with your explanation of how people choose residencies (interest, dislikes, competitiveness, and financial/lifestyle).

'the money/lifestyle honestly did play a huge part in deciding between anesthesia, cardiology, and surgery'

yeah that's exactly what i'm saying. money and lifestyle play enormous roles in people's decision makings. that's my message to the op and its a beneficial one. perhaps realize why you favor anesthesia so much. is it perhaps possible the money/life put it way way way up on your differential?

and mista, i have done a rotation in gas. i do know what i'm talking about a little bit. and quite frankly i'm not very impressed. if you were impressed, go for it by all means. but please be honest with yourself and realize that if there's some new legislation passed that gave anesthesia peds money and cards hours starting next year, your a$$ would be applying to the next free internal medicine spot in the country.

 

[Hoya11]

but you could say that about anything.. if IM had nothing but cardiology hours and crap money would you go into that? Are you absolutely passionate about IM? I mean come on...

 

[Mista Suprane]

perhaps realize why you favor anesthesia so much. is it perhaps possible the money/life put it way way way up on your differential?

i already admitted that money/lifestyle played a huge part, with regards to differentiating between surgery, cards, and anesthesia. but it does seem quite clear that my definition of money/lifestyle is different than yours. it will be nice to work 55-65 hrs a week as an attending, pulling between 200-300K (depending on academic vs. private practice). no patients calling you in the middle of the night, no long term care, no headaches. although i will admit that in-house overnight call as an attending is a small negative. i will totally concur that all of this stuff is great, and a huge reason to choose anesthesia. but...

read a book and recline while the surgeon works like a dog

easier-to-perform/chill jobs out there.

these statements are simply not true. if you said you did a rotation in gas, that's great. even though you did, however, you still have very little knowledge of what an anesthesiologist actually does. i won't deny that there are book/coffee/easy/chill moments, but THAT is the minority of the time, and not why i'm choosing it. my love of procedures, and strengths in physio/pharm combined with MY above hours/lifestyle definition sealed the deal for me. those going into anesthesia because they agree with your comments are gonna be real pissed. i think it is important for people who are considering it as a possible career choice to know this.

as i said in my original post, when they're working, they're WORKING. shadow a private practice anesthesiologist at a busy hospital, and you'll see. since you're "not impressed", however, you can just take that free IM spot.

 

[nutcancer]

'if IM had nothing but cardiology hours and crap money would you go into that?'

hell no. i'm keeping it real. i'm not even going into IM anyway.

but to mista , you're right, those statements about anesthesia being easy may not be true and definitely do not help the op make an informed decision -- you're right about that and i'm sorry about that. i guess i was just spewing the what most docs (you call them misinformed and they very well could be) think about anesthesia, especially compared to fields like surgery and cardiology.

to each his own. you sound sincerely enthusiastic and genuinely interested in your chosen field -- that will work out really well for you. perhaps my comments are beneficial afterall if people interested in anesthesia for the wrong reasons contrast your good reasons and my superficial ones and avoid making a mistake.

 

[Gem134]

Gentlemen! let's not argue here.

As for the OP, after reading through all these comments I think I might look into anesthesia. I like parts of it pretty well, but I am worried I might get bored. I am going to schedule a rotation and check it out. It's hard to balance your interests, competitiveness, financial/lifestyle issues and come up with a field of medicine that somehow answers all those questions.

I am struggling with these issues too!

 

[LurkNoMore]

I think thats a good idea Gem.... just as long as you dont bump me from an early rotation that will help me decide what I want to do . I think there are a lot of misconceptions out there about anesthesia, and I don't claim to understand all that is involved..... q3-9 call as an attending seems to be standard in most parts and the average work week is ~61 hours per week, definitely not slack in the eyes of most. As far as excitement, trauma and big cases will get your heart-rate going, as will a difficult line placement or establishing an airway when the O2 sat starts dropping. In the end it all comes down to "is it right for you" (and me for that matter....), must answer that question first and foremost! Additionally, there are a good many spots (more than in Neurosurg, derm, ortho.... etc.) which makes it "easier" (see other ridiculous argument on this topic in gasforums) to get into than a good many fields, though it is getting more competitive, especially at the top, desirable programs.