Serious post: Why dual degree OMS residency?

[D1Bound]

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I just have to ask this question. It's been asked many times, and I've asked several surgeons personally, but I still have not received a concrete answer. What is the point of the dual degree OMS program? The following reasons are what I have gathered
Dual degree aids in
-Certain fellowship opportunities. Ex full body cosmetics. This is the only one that I know of. There are single degree surgeons doing microvascular and many other subspecialties.
-Applying to medical residency. If you would like to be an ENT, orthopedic surgeon, etc, that requires an MD.
-Recognition of scope of practice in Europe. From what I have seen, the only way to practice full orthgnathic, TMJ, trauma, craniofacial, etc in Europe is to have an MD.

In your response, I ask that you do not use emotion. Please do not use anecdotal unsubstantiated reasons why an MD is required for a certain aspect of OMS. Please provide factual evidence. I promise I'm not trolling. I have to frame it this way because it seems that when I ask, I do get a ton of emotion in one's response both from single and dual degree surgeons on all sides of this issue.

 

[White_Sponge_Nevus]

I wish that SDN was as popular today as it was 10 years ago. It is crazy to think I was in undergrad 10 years ago applying to dental school and scheduling my first interviews. There were a lot more actively posting dental students applying to OMFS/OMFS residents/oral surgeons at that time. I don't know if Reddit/other social media has made SDN become less popular. But I think that @nade0016 @OMSDoc @George Lincoln @omfsing are the most seasoned and respected voices left. A ton old timers (Gary Ruska, Armorshell, Bereno etc) would have interesting mid to late career perspective about all the OMFS threads these days and I would love to hear them.

But anyways, your specific question. There really is no tangible objective benefit that played into my decision making. Mine was based on fear. Turns out fear of being at a disadvantage for fellowships (generally unfounded). Fear of difficulty in obtaining hospital privileges (have not heard in my circle of this being an issue). Fear of changes to anesthesia privileges (state specific issue that might have the MD come into play but nobody can product this and I'm sure OMSPAC will empty the coffers to protect 4 and 6 alike rather than sacrifice the ability for the 4's to do in-office anesthesia to save the 6's).

The only people I know who are currently 6 year residents who don't regret their choice to do 6 vs 4 either were independently wealthy to start residency, or married other people in the dental/medical field who are already out of residency financially supporting them. All other current 6 year residents I know currently regret their choice. However, I do not know any practicing 6 year grads who regret their choice to do 6. Take that for what you will.

I would guess you've already listened to the Engelstad substack on the topic but can't recommend it enough for dental students trying to decide between 4 & 6.

 

[D1Bound]

I wish that SDN was as popular today as it was 10 years ago. It is crazy to think I was in undergrad 10 years ago applying to dental school and scheduling my first interviews. There were a lot more actively posting dental students applying to OMFS/OMFS residents/oral surgeons at that time. I don't know if Reddit/other social media has made SDN become less popular. But I think that @nade0016 @OMSDoc @George Lincoln @omfsing are the most seasoned and respected voices left. A ton old timers (Gary Ruska, Armorshell, Bereno etc) would have interesting mid to late career perspective about all the OMFS threads these days and I would love to hear them.

But anyways, your specific question. There really is no tangible objective benefit that played into my decision making. Mine was based on fear. Turns out fear of being at a disadvantage for fellowships (generally unfounded). Fear of difficulty in obtaining hospital privileges (have not heard in my circle of this being an issue). Fear of changes to anesthesia privileges (state specific issue that might have the MD come into play but nobody can product this and I'm sure OMSPAC will empty the coffers to protect 4 and 6 alike rather than sacrifice the ability for the 4's to do in-office anesthesia to save the 6's).

The only people I know who are currently 6 year residents who don't regret their choice to do 6 vs 4 either were independently wealthy to start residency, or married other people in the dental/medical field who are already out of residency financially supporting them. All other current 6 year residents I know currently regret their choice. However, I do not know any practicing 6 year grads who regret their choice to do 6. Take that for what you will.

I would guess you've already listened to the Engelstad substack on the topic but can't recommend it enough for dental students trying to decide between 4 & 6.

Where do I view Engelstad sub stack?

 

[White_Sponge_Nevus]

So you're thinking about getting an MD during your OMS residency? | Part 1 of 3

Degrees make a difference, but they don't matter

markengelstad.substack.com

There are three parts, all worth the listen. Approx 2 years old but very relevant.

Since then, anecdotally seeing a lot more people getting tossed from 6 year programs due to failing to meet meds school requirements and overall applicant:spot ratio dropping. Not even mentioning Big Beautiful Bill. Lots to think about.

 

[D1Bound]

So you're thinking about getting an MD during your OMS residency? | Part 1 of 3

Degrees make a difference, but they don't matter

markengelstad.substack.com

There are three parts, all worth the listen. Approx 2 years old but very relevant.

Since then, anecdotally seeing a lot more people getting tossed from 6 year programs due to failing to meet meds school requirements and overall applicant:spot ratio dropping. Not even mentioning Big Beautiful Bill. Lots to think about.

One thing that stood out to me was about credentials and hospital revenue. If I’m a single degree, fellowship trained OMS, and can produce complex cases, don’t the administrative leaders of the hospital have every interest to credential me?

 

[deleted1203555]

Fear of changes to anesthesia privileges (state specific issue that might have the MD come into play but nobody can product this and I'm sure OMSPAC will empty the coffers to protect 4 and 6 alike rather than sacrifice the ability for the 4's to do in-office anesthesia to save the 6's).

If anesthesia privileges are revoked for omfs, having a MD would do nothing to benefit the provider.

The argument against omfs performing their own office based anesthesia has nothing to do with having an md or not. It’s about the surgeon administering his own anesthesia simultaneously.

This idea of having an md which can help protect one’s privilege is a total fallacy. It’s mainly believed by dual degree residents such as yourself.

Omfs general anesthesia permits are given through the state dental board. Not the state medical board.

Dental anesthesiologists do not have an md, yet they obviously have the ability now and forevermore, to administer ga.

 

[White_Sponge_Nevus]

If anesthesia privileges are revoked for omfs, having a MD would do nothing to benefit the provider.

The argument against omfs performing their own office based anesthesia has nothing to do with having an md or not. It’s about the surgeon administering his own anesthesia simultaneously.

This idea of having an md which can help protect one’s privilege is a total fallacy. It’s mainly believed by dual degree residents such as yourself.

Omfs general anesthesia permits are given through the state dental board. Not the state medical board.

Dental anesthesiologists do not have an md, yet they obviously have the ability now and forevermore, to administer ga.

All things I came to learn after my decision of 4 vs 6 wa already made. For all these reasons you listed I agree and find it incredibly unlikely a change in ability to administer anesthesia being dictated by 4 vs 6

 

[White_Sponge_Nevus]

One thing that stood out to me was about credentials and hospital revenue. If I’m a single degree, fellowship trained OMS, and can produce complex cases, don’t the administrative leaders of the hospital have every interest to credential me?

Increasingly as years go on, especially now that adminstrators make decisions and not physicians, they have every interest in generating revenue regardless of the degree of the person who is going to generate it, yes

 

[Big Time Hoosier]

I do not know any practicing 6 year grads who regret their choice to do 6.

Do you know any who regret doing a 3 year program?

Big Hoss

 

[OrphanageCaretaker]

1. Hospital privileges
2. Marketing

 

[deleted1203555]

Increasingly as years go on, especially now that adminstrators make decisions and not physicians, they have every interest in generating revenue regardless of the degree of the person who is going to generate it, yes

For decades (century) that omfs have been in existence, hospital privileges were never a question for core based omfs privileges regardless of single or dual degree status.

This has not changed over time. Every hospital in the country will grant core omfs privileges, in the past and present, to single degree omfs.

Having an MD does not influence or make it more easier to obtain privileges for core omfs.
As long as you send in your dental license, certificate, proof of malpractice coverage, and fill out their forms, they will grant you core privileges.

Again this is a false belief of mostly dual degree residents in training.

1. Hospital privileges
2. Marketing

 

[D1Bound]

For decades (century) that omfs have been in existence, hospital privileges were never a question for core based omfs privileges regardless of single or dual degree status.

This has not changed over time. Every hospital in the country will grant core omfs privileges, in the past and present, to single degree omfs.

Having an MD does not influence or make it more easier to obtain privileges for core omfs.
As long as you send in your dental license, certificate, proof of malpractice coverage, and fill out their forms, they will grant you core privileges.

Again this is a false belief of mostly dual degree residents in training.

still need a valid reason other than the ones I raised lol

 

[omfsing]

I agree with everything said above.

One thing to consider, take it for what it’s worth, is that the dual degree track only adds two extra years (vs. 4) to obtain an MD, the most coveted initials on the planet.

 

[D1Bound]

I agree with everything said above.

One thing to consider, take it for what it’s worth, is that the dual degree team only adds two extra years (vs. 4) to obtain an MD, the most coveted initials on the planet.

That's an emotional reason. So you get the MD. Will you have enough ACGME time to be licensed? And then you're licensed. What does it do?!?!?!?!?

 

[Wisetoothshucker]

Non-objective reason here but I do think it’s helpful for fellowships. There are many single degree docs in these fields but I think most of them would’ve chosen the MD had the situation allowed them.

I did a noncat at a 4 yr cancer program. I do think it’s nice for the patient to see the MD, not that it changes any skill or anything. But intuitively if you’re a patient with an avulsed scalp and need a lattismus dorsi flap, why are you seeing someone with a DDS? Again not an objective finding but just my opinion.

Of course most of us will not be doing that kind of work but if someone wants to I think it’s beneficial. But for 99% of us this isn’t relevant lol

 

[deleted1203555]

Non-objective reason here but I do think it’s helpful for fellowships. There are many single degree docs in these fields but I think most of them would’ve chosen the MD had the situation allowed them.

I did a noncat at a 4 yr cancer program. I do think it’s nice for the patient to see the MD, not that it changes any skill or anything. But intuitively if you’re a patient with an avulsed scalp and need a lattismus dorsi flap, why are you seeing someone with a DDS? Again not an objective finding but just my opinion.

Of course most of us will not be doing that kind of work but if someone wants to I think it’s beneficial. But for 99% of us this isn’t relevant lol

Nailed it right on the spot.
Less than 1 percent of omfs will actually be doing head and neck or pursue a fellowship in head and neck.

Obviously if your intent is to do expanded scope surgery then by all means - you should definitely be targeting dual degree programs as they will set you up better for fellowships.

The vast majority of omfs residents and practicing oral surgeons have far different goals. We want to be high producers.

 

[DentistRays]

Nailed it right on the spot.
Less than 1 percent of omfs will actually be doing head and neck or pursue a fellowship in head and neck.

Obviously if your intent is to do expanded scope surgery then by all means - you should definitely be targeting dual degree programs as they will set you up better for fellowships.

The vast majority of omfs residents and practicing oral surgeons have far different goals. We want to be high producers.

Can 4 yr apply to H&N fellowships? Or is it only for 6 years?

 

[Wisetoothshucker]

Can 4 yr apply to H&N fellowships? Or is it only for 6 years?

They can. I think some fellowships may say dual degree only, but if you schmooze the fellowship director enough you'll get in as a single degree. It's helpful to have the dual degree though.

 

[D1Bound]

They can. I think some fellowships may say dual degree only, but if you schmooze the fellowship director enough you'll get in as a single degree. It's helpful to have the dual degree though.

I know a single degree that’s doing head and neck. Again, I promise I am not trolling. How is it helpful to have the dual degree?

 

[deleted1203555]

I know a single degree that’s doing head and neck. Again, I promise I am not trolling. How is it helpful to have the dual degree?

You’re asking a question that is pretty irrelevant to 99 percent of oral surgeons (both single and dual degree).

99 percent of us couldn’t care less about head and neck and don’t want to have anything to do with it.

 

[somefuturedoc]

I think this thread shows there are no purely objective benefits. You have to decide if the potential subjective benefits (to you or your patients) are worth it.

 

[JerrysFirstMolar]

I know a single degree that’s doing head and neck. Again, I promise I am not trolling. How is it helpful to have the dual degree?

Sure, it’s not impossible to do with a 4 year but that doesn’t negate the fact that it is helpful/probably easier with a 6.

I think this thread shows there are no purely objective benefits. You have to decide if the potential subjective benefits (to you or your patients) are worth it.

This. I’ll say one thing that hasn’t been overtly said. Ego. Not necessarily a bad thing, but some just want the MD. I think I can do it so I want it. I am an applicant rn but I feel that I would enjoy med school (given I get into one of the programs with cheaper tuition). Especially when many end up doing non-cats, making it 5 years vs 6 with a bonus of a degree that may have benefits, thought not concrete. Again, not an objective benefit, but I have also felt that if I am to be practicing surgery, especially in an OR setting, I should have the degree classically associated with it. My patient may want this too… not always but sometimes.

 

[deleted1157770]

The big beautiful bill is only going to further hurt 6 year programs and push applicants towards 4 years. Having to take out private loans for medical school since most will have hit their gov loan cap between undergrad and dental school is going to be a big deterrent for 6 year programs.

I imagine they’ll still fill their spots, but similar to expensive private dental schools, it will be with students who didn’t match or preferred the 4 year option and matched lower on their list because they’d rather be an OMS than not.

 

[Big Time Hoosier]

In an battle of ego between oral surgeons, who would win?

A) 4 year OMFS from a very reputable hospital/university.

B) 6 year OMFS from a low tier/no-name program.

Big Hoss

 

[deleted1203555]

This. I’ll say one thing that hasn’t been overtly said. Ego. Not necessarily a bad thing, but some just want the MD.

Do you not know how to read?
The OP asked for objective benefits. If you have nothing to contribute then don’t post anything.

 

[deleted1203555]

The big beautiful bill is only going to further hurt 6 year programs and push applicants towards 4 years. Having to take out private loans for medical school since most will have hit their gov loan cap between undergrad and dental school is going to be a big deterrent for 6 year programs.

I imagine they’ll still fill their spots, but similar expensive private dental schools, it will be with students who didn’t match or preferred the 4 year option and matched lower on their list because they’d rather be an OMS than not.

Thanks but the OP didn’t ask for this.
If you have anything to contribute to his original question then don’t post in this thread.

 

[deleted1203555]

In an battle of ego between oral surgeons, who would win?

A) 4 year OMFS from a very reputable hospital/university.

B) 6 year OMFS from a low tier/no-name program.

Big Hoss

We appreciate the comedic relief but this is getting way off topic.

 

[deleted1157770]

Thanks but the OP didn’t ask for this.
If you have anything to contribute to his original question then don’t post in this thread.

We appreciate the comedic relief but this is getting way off topic.

Do you not know how to read?
The OP asked for objective benefits. If you have nothing to contribute then don’t post anything.

lol wtf

 

[Jaa_]

I think that the largest objective benefit of the MD is more comfort in medical management of complex patients who are admitted to your service.

 

[deleted1157770]

I think that the largest objective benefit of the MD is more comfort in medical management of complex patients who are admitted to your service.

i find it hard to believe that 4-8 weeks on the different clerkships at the level of a student really moves the needle all that much in terms of medical management.

Not only that, while interviewing most of 6 year program residents said “most of us just do the bare minimum. You only need to pass each clerkship, shelf exam, and Step, so it’s not stressful at all. Tons of down time, and all of us moonlight”.

 

[JerrysFirstMolar]

Do you not know how to read?
The OP asked for objective benefits. If you have nothing to contribute then don’t post anything.

Do you know how to read?
The post says ‘why 6 year’/‘what is the point’. The subjectives people have mentioned are why.
Maybe there aren’t objectives as he asks for but again this doesn’t negate why people choose.
Above all, looking to match at a quality program regardless of an extra degree or not. Everyone should strive for this.

 

[D1Bound]

Sure, it’s not impossible to do with a 4 year but that doesn’t negate the fact that it is helpful/probably easier with a 6.


This. I’ll say one thing that hasn’t been overtly said. Ego. Not necessarily a bad thing, but some just want the MD. I think I can do it so I want it. I am an applicant rn but I feel that I would enjoy med school (given I get into one of the programs with cheaper tuition). Especially when many end up doing non-cats, making it 5 years vs 6 with a bonus of a degree that may have benefits, thought not concrete. Again, not an objective benefit, but I have also felt that if I am to be practicing surgery, especially in an OR setting, I should have the degree classically associated with it. My patient may want this too… not always but sometimes.

Emotion. I know 2 microvascular OMFS single degree. I know one graduating going into head and neck single degree. Dentists have performed oral and maxillofacial surgery since it was pioneered in WW1. Dentists also pioneered anesthesia. A dental degree is classically associated with these things. It’s within their scope.

 

[White_Sponge_Nevus]

i find it hard to believe that 4-8 weeks on the different clerkships at the level of a student really moves the needle all that much in terms of medical management.

Not only that, while interviewing most of 6 year program residents said “most of us just do the bare minimum. You only need to pass each clerkship, shelf exam, and Step, so it’s not stressful at all. Tons of down time, and all of us moonlight”.

I will say that being forced to study for shelf exams/Step 2 provides you with infinitely more opportunity to learn medicine than does being forced to pass Step 1. A completely different discussion, but I wish they would let all OMFS people skip medical school didactics and if they're gonna force us to be in med school, hold us more accountable than the average M3 and then we'd learn more. Or have us be IM off service residents as paid intern labor. But a lot of people are happy to skate like you described.

 

[JerrysFirstMolar]

Emotion. I know 2 microvascular OMFS single degree. I know one graduating going into head and neck single degree. Dentists have performed oral and maxillofacial surgery since it was pioneered in WW1. Dentists also pioneered anesthesia. A dental degree is classically associated with these things. It’s within their scope.

Ok, if you are exclusively looking for objectives, maybe there aren’t.

People can be emotionally driven to something and that’s ok. Much respect to anyone who goes through 4 or 6 years of training. It’s nice that the field gives an option.

 

[Jaa_]

i find it hard to believe that 4-8 weeks on the different clerkships at the level of a student really moves the needle all that much in terms of medical management.

Not only that, while interviewing most of 6 year program residents said “most of us just do the bare minimum. You only need to pass each clerkship, shelf exam, and Step, so it’s not stressful at all. Tons of down time, and all of us moonlight”.

- Clerkships (like any rotation) are what you make of them.
- yes, med school is not hard relative to the other years, but that doesn’t mean it’s always easy.
- it would be unusual for someone to pass 6 shelf exams, step 1,2, and 3 and not have more confidence in medical management of patients.

I respect my 4 year colleagues and I think most of them would agree with what i said.

 

[omfsing]

That's an emotional reason. So you get the MD. Will you have enough ACGME time to be licensed? And then you're licensed. What does it do?!?!?!?!?

Bro, relax. I think you already know the answer to your question.

I used to think it’s for hospital privileges or if H+N guys wanted to practice they needed it but I soon learned that wasn’t true at all.

Sure I’ve had some patients choose me because they’re happy I have an MD, but I don’t think that is a significant practice booster by any means.

End of the day, it’s basically an emotional/ego reason.

You have to ask yourself do you want it or do you not. I don’t think the MD really does anything but I do take pride (my parents moreso haha) knowing I have an MD.

But make no mistake, it’s my DDS I have all to thank for giving me this life

Some side points:
Also, I have enough ACGME to be licensed in certain states. In NC, you can practice under your MD if you don’t want to get your dds license because MD licensure in most states is easier to obtain.

 

[D1Bound]

Bro, relax. I think you already know the answer to your question.

I used to think it’s for hospital privileges or if H+N guys wanted to practice they needed it but I soon learned that wasn’t true at all.

Sure I’ve had some patients choose me because they’re happy I have an MD, but I don’t think that is a significant practice booster by any means.

End of the day, it’s basically an emotional/ego reason.

You have to ask yourself do you want it or do you not. I don’t think the MD really does anything but I do take pride (my parents moreso haha) knowing I have an MD.

But make no mistake, it’s my DDS I have all to thank for giving me this life

Some side points:
Also, I have enough ACGME to be licensed in certain states. In NC, you can practice under your MD if you don’t want to get your dds license because MD licensure in most states is easier to obtain.

Lol I’m chill. If you break your hand and retire from OMS can you practice primary care? Are you credentialed to do that?

 

[Jaa_]

Emotion. I know 2 microvascular OMFS single degree. I know one graduating going into head and neck single degree. Dentists have performed oral and maxillofacial surgery since it was pioneered in WW1. Dentists also pioneered anesthesia. A dental degree is classically associated with these things. It’s within their scope.

State laws vary on what the scope of practice of a DDS is and in some states, flap harvests outside the head and neck region push that boundary. For example, look into the NY Dental Practice Act. Other specialties lobby for these restrictions because they want a bigger slice of the pie and can often win because the general public/law makers don’t want an oncologist without an MD.

 

[Allsmiles!]

I just have to ask this question. It's been asked many times, and I've asked several surgeons personally, but I still have not received a concrete answer. What is the point of the dual degree OMS program? The following reasons are what I have gathered
Dual degree aids in
-Certain fellowship opportunities. Ex full body cosmetics. This is the only one that I know of. There are single degree surgeons doing microvascular and many other subspecialties.
-Applying to medical residency. If you would like to be an ENT, orthopedic surgeon, etc, that requires an MD.
-Recognition of scope of practice in Europe. From what I have seen, the only way to practice full orthgnathic, TMJ, trauma, craniofacial, etc in Europe is to have an MD.

In your response, I ask that you do not use emotion. Please do not use anecdotal unsubstantiated reasons why an MD is required for a certain aspect of OMS. Please provide factual evidence. I promise I'm not trolling. I have to frame it this way because it seems that when I ask, I do get a ton of emotion in one's response both from single and dual degree surgeons on all sides of this issue.

Are you wanting to go into OMFS? Are you trying to determine if you will be applying to 4 vs 6? Why start another stupid thread on a topic that has been beaten down to death. You can read a dozen other threads on this topic and it’s the same every time. I have to say, as time goes by, I’m finding myself wondering what has happened to SDN.

 

[White_Sponge_Nevus]

I have to say, as time goes by, I’m finding myself wondering what has happened to SDN.

I miss the old SDN so much

 

[D1Bound]

I miss the old SDN so much

Heck isn’t it the same WAMC, choose the cheapest school, how competitive is ortho, OMS, etc? And a troll post from BigTimeHoosier for old times sake?

 

[omfsing]

Lol I’m chill. If you break your hand and retire from OMS can you practice primary care? Are you credentialed to do that?

Yes I believe you can

 

[Wisetoothshucker]

lol wtf

He is imagining that he’s an untouchable attending abusing his residents. Toothnumber32, this is an Internet forum with random strangers. We are not obliged to stay on topic for you, thanks. You can fire me from your imaginary residency program.

 

[deleted1203555]

Yes I believe you can

one would have to perform a 3 year residency in family medicine to practice family medicine. Am I correct ?

 

[deleted1203555]

He is imagining that he’s an untouchable attending abusing his residents. Toothnumber32, this is an Internet forum with random strangers. We are not obliged to stay on topic for you, thanks. You can fire me from your imaginary residency program.

Wisetoothshucker

Thanks for your display of keyboard courage. Carry on.

 

[yappy]

That's an emotional reason. So you get the MD. Will you have enough ACGME time to be licensed? And then you're licensed. What does it do?!?!?!?!?

If clinicians depart from their clinical career to work in industry or consulting, an MD may be beneficial.

 

[deleted783936]

I've met more 4 year residents than 6 year residents who don't know how to do basic hospital management which led to bad patient outcomes. Alot of 4 year spots require 1-3 hospital years prior to matching into them. others requiring you to be a non-traditional (>age 26 when applying to their program because of life experience..etc.)

Just get the MD if you can match into an MD integrated program less than the age 26. its proof for the rest of your life you were smart enough to be a real doctor. it also lets you work in nicer hospitals later on in your career.

The 4 year guys will never have that proof and a lot of them will fight that battle the rest of their lives.

 

[D1Bound]

If clinicians depart from their clinical career to work in industry or consulting, an MD may be beneficial.

Thank you for a helpful comment

 

[somefuturedoc]

I've met more 4 year residents than 6 year residents who don't know how to do basic hospital management which led to bad patient outcomes. Alot of 4 year spots require 1-3 hospital years prior to matching into them. others requiring you to be a non-traditional (>age 26 when applying to their program because of life experience..etc.)

Just get the MD if you can match into an MD integrated program less than the age 26. its proof for the rest of your life you were smart enough to be a real doctor. it also lets you work in nicer hospitals later on in your career.

The 4 year guys will never have that proof and a lot of them will fight that battle the rest of their lives.

Sounds like a reflection on the quality of your program more than anything

And let’s be real. Most medically complex patients get a medicine consult anyways, across pretty much all services

 

[HockeyDocOMFS]

Bro you have literally been lurking SDN for years, have graduated dental school, and are in residency... Not sure what you're trying to get from this?

At the end of the day, people should go to the best program out there. There are some BAD OMFS programs. And I mean really bad. It is better to learn a broad scope and then narrow it once you finish residency - it is impossible to do the opposite unless you do a fellowship. My rank list was based on location and scope of practice of the residency. Everyone weighs things differently.