should I stay or should I go?

[manicguacamole]

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Hi, I have been reading these forums for a while now; this is my first post. I wanted your opinions on a dilemma I've been wrestling with. I am now a 4th year medical student applying for a pathology residency. The institution I'm at now is a university-based tertiary-care center. It handles around 15,000 surgical and 16,000 cytology specimens a year. The program here has around 10 residents, who seem pretty happy. I suppose this is a better program than would be found at a community-based hospital, but as far as I know it is not in any way a prestigious place to train. I'm pretty much guaranteed a spot at this institution, and I have very strong family reasons to stay here. So my question is, how much would my training and future competitiveness for fellowships and such be hindered by training at a place that is not a well-known pathology program? I think I would be a competitive candidate for, if not first-tier, at least fairly decent programs (good clinical and pre-clinical grades, USMLE 240s.) However, because of my family situation, I'd really like to stay here for residency. (I'd likely be able to go elsewhere for fellowships.)

I thought I'd just see if anyone had any thoughts on this. I know I'm being vague, which might make offering advice harder. I'm certainly willing to read a lot and study hard, but I'm worried that I might not see the variety of things one might elsewhere. How much of residency is learning from a text versus from experience with cases? Anyway, any input anyone has would be appreciated.

Thanks

 

[garfield]

That's a tough decision. It's still possible to be competitive coming from a small program, however you'll have to work a lot harder for it. Path is a relatively small specialty, and lots of the prestigious fellowships and jobs are based on connections (who you know, that sort of thing). You do have to do a lot of self-learning via textbooks, but it is easier to retain knowledge from the cases you see in person. That being said, there is life outside residency. So, location is a consideration when deciding on programs. It's early to make hard and fast decisions... would still apply to other programs, just to see what's out there. Get other opinions. Then, make the hard decisions for the match list.

 

[yaah]

Garfield's right - it is a tough decision. I would say though that specimen volume and variety is important for residency. A place that has <20,000 specimens per year often doesn't provide a ton of variety. There are just a lot of things that you won't see a lot of.

Many believe though that where you do your fellowship is as important as where you do your residency, so if you think this program is appropriate and provides you with a good learning environment I don't think you will be held back much. Fellowships are competitive, yes, but if you distinguish yourself from a good program with research, good recommendations, or whatever you will be able to get a good fellowship.

It also depends on what your career goals are. If you are set on being an academic pathologist, it might help to train at a larger program. If your goal is to stay in the same area, training at a local facility is often helpful because everyone knows everybody.

The good thing about interview season is that you can look around and think about it some more. Visit some other programs, see if you would be happy, or perhaps see if they would be a better fit for you. You may find your home program is the best fit, who knows? Your home program may be like where i went to med school - would be thrilled to have you come there for residency but also willing to help you find the best fit for you. You won't insult them if you go somewhere else.

p.s.: Manic guacomole? Sounds spicy!

 

[b&ierstiefel]

p.s.: Manic guacomole? Sounds spicy!

Spicier than a hot steaming turd...where do I get some of dat?

 

[GreatPumpkin]

Your best chance at getting a fellowship in a certain subspecialty is to go to a program that offers it and stay there. Many programs gladly recruit from within.

Another reason to go to a place that offers the subspecialty is that likely the head of that fellowship will be well connected with the other fellowship directors in that area.

Getting fellowships are more about who you know, than what you know or how good you look on paper. Sad but true.

 

[Doctor B.]

Getting fellowships are more about who you know, than what you know or how good you look on paper. Sad but true.

Fortunately or unfortunately, that seems to be true.

Hey, I just noticed the Great Pumpkin is now Chief Pumpkin! Congrats!

I agree with Yaah, 15,000 specimens may not be enough if that is the only hospital at which you train; it depends on what sort of surgeons you have and how many consult cases get sent there.

It's tough to balance personal and professional criteria when choosing residency and fellowships. I've always put more weight on personal criteria b/c my wife, friends and family are more important to me than anything. Is there another residency within reasonable distance that may more robust numbers?

 

[tsj]

Fortunately or unfortunately, that seems to be true.

Hey, I just noticed the Great Pumpkin is now Chief Pumpkin! Congrats!

I agree with Yaah, 15,000 specimens may not be enough if that is the only hospital at which you train; it depends on what sort of surgeons you have and how many consult cases get sent there.

It's tough to balance personal and professional criteria when choosing residency and fellowships. I've always put more weight on personal criteria b/c my wife, friends and family are more important to me than anything. Is there another residency within reasonable distance that may more robust numbers?

UCSF and Stanford don't get 20,000 a year (close to 15,000). But supposedly they are pretty fair programs.

 

[yaah]

Well it depends a lot on what makes up the 15K specimens. Some of the smaller programs may have 15000 specimens and 75% of them are office cervical/endometrial biopsies, GI polyps, and BCCs. If going on an interview to a place with <20,000 I would make sure I ask about specimen volume, adequate training, and the like. Perhaps they get tons of consults.

 

[LADoc00]

UCSF and Stanford don't get 20,000 a year (close to 15,000). But supposedly they are pretty fair programs.

Youre an idiot, Stanford is well over 50,000 surgicals nongyn nonconsult a year. UCSF is similar. Nice talking out of your ass.

 

[tsj]

No they don't. I rotated there last year and they were on pace for around 14000 or so. The other residents stated they typically get about 14-15000 surgicals a year at parnassus. There are a few thousand also at SFGH and the VA but those are taken care of by UCSF residents that rotate there so in essence it averages to even less.

They do get something like 30,000 derm specimens, but those are "outside" the surg path department.

Stanford's surgicals are the same. I know I just went through the application process and wrote down the numbers for every program I applied to. UCSD was about 13000. UCLA had the most in CA with somewhere in the low 20s. These are in house surgical specimens and UCLA's doesn't include GI biopsies. I remember writing down that they do a ton of those (one of the biggest centers on the west coast) but GI has its own histo lab. I have a notebook with the stats on 17 different programs.

By far the busiest place is MGH.

Where did you do residency and what makes you an expert about California programs?

 

[LADoc00]

No they don't. I rotated there last year and they were on pace for around 14000 or so. The other residents stated they typically get about 14-15000 surgicals a year at parnassus. There are a few thousand also at SFGH and the VA but those are taken care of by UCSF residents that rotate there so in essence it averages to even less.

They do get something like 30,000 derm specimens, but those are "outside" the surg path department.

Stanford's surgicals are the same. I know I just went through the application process and wrote down the numbers for every program I applied to. UCSD was about 13000. UCLA had the most in CA with somewhere in the low 20s. These are in house surgical specimens and UCLA's doesn't include GI biopsies. I remember writing down that they do a ton of those (one of the biggest centers on the west coast) but GI has its own histo lab. I have a notebook with the stats on 17 different programs.

By far the busiest place is MGH.

Where did you do residency and what makes you an expert about California programs?

Approximately 26,500 surgical specimens originating from the Stanford Health Services Operating Rooms, Stanford University Clinics, other area clinics, or from the private and independent Palo Alto Surgicenter are accessioned yearly. Another 13,000 cases are reviewed when patients, whose pathology specimens were originally examined elsewhere, are referred to Stanford for treatment or for consultation.
At the Veterans Administration Palo Alto Health Care Systems (VAPAHCS), over 8000 surgical specimens are examined annually. These originate from the operating rooms and clinics. The areas that are most active are Dermatology, GI endoscopy and Urology.
-From the Stanford website so anyone can verify
http://pathology.stanford.edu/patient_care/surgical.html

Thats nearly 50K right there. Why the lies Tsj?

AND to add insult to your injury from the UCLA website:
"Approximately 25,000 surgical specimens and 30,000 cytologic specimens are reviewed per year at UCLA by faculty in the various anatomic pathology divisions"
http://www.pathology.ucla.edu/index.htm

Again, why the lies?

Rereading your post, what incredible dork writes down the number of specimens as a basis to pick a residency? That has to be dumbest thing Ive ever heard of.

 

[tsj]

I wanted to go to a program that had at least 20,000 specimens a year. I felt that UCSF and UCSD and programs that had under 15,000 or less were just too few.

It is interesting to note that you say people get hired on personality and not credentials. You would know as you have no job but all the credentials in the world having trained at LAC, Brigham, Wash U, Stanford etc...

Thanks for calling me a dork and an idiot.

 

[LADoc00]

I wanted to go to a program that had at least 20,000 specimens a year. I felt that UCSF and UCSD and programs that had under 15,000 or less were just too few.

It is interesting to note that you say people get hired on personality and not credentials. You would know as you have no job but all the credentials in the world having trained at LAC, Brigham, Wash U, Stanford etc...

Thanks for calling me a dork and an idiot.

LOL, I have a job. Nice try though.

Sigh, I will apologize to you Tsj for the idiot/dork comment. Was over the top, though I didnt start this. I will say I was very enthusiastic about path until I came to LA and was dumped by 4 chicks in a row who either felt I didnt make enough money or wasnt as exciting as they expected. When I finally had enough of this crap, Im trying to find a job elsewhere and am having a tougher time than I ever imagined. When radiology residents can pick a beach in CA and go there and Im one of 20 people applying to the path group in Fresno, I get pissed. Maybe it will all work out, dunno. Really Im at the point of not even caring anymore.

 

[desmangt]

TSJ wrote "By far the busiest place is MGH."

Mount Sinai has the largest case load in the country, not MGH. They have the 2nd largest. I think some of your numbers might be off. What source are you using? I'm just curious.

 

[PathOne]

I agree with previous posts that 15K/specimens/yr. doesn't necessarily tell you what you want to know. Actually talked to a PD from one of the absolute top US programs today, and he said that they had 100+ applications for their fellowships. Basically, the vast majority was nearly identical in terms of required experience etc., so except for the very best and the unacceptable, it was a question of assembling a group of fellows who would function well as a group. That was his main concern.

I'd find out more about the diversity of specimens in the program you're thinking about. Regardless of wether you'd be choosing a fellowship or go directly into, say, a community/private program, you'd want to be pretty sure that you have had a solid exposure to a lot of different stuff. But if veriety is no problem, a smaller program could make you more well-rounded than a large and highly specialized program. Personally, I would mainly worry about the attendings' willingness and aptitude for training you, rather than letting you do all the routine stuff and hogging all the difficult and interesting cases for themselves. Best of luck...

 

[Zoloft]

TSJ wrote "By far the busiest place is MGH."

Mount Sinai has the largest case load in the country, not MGH. They have the 2nd largest. I think some of your numbers might be off. What source are you using? I'm just curious.

Yeah I think some of those numbers have to be off. How do places like Mt. Sinai have 150k specimens a year when there are 4 other big academic hospitals in the city, and UCSF, Stanford, and UCLA have apporx 20k when they are the only big names in town?

 

[Doctor B.]

I agree with previous posts that 15K/specimens/yr. doesn't necessarily tell you what you want to know.

That's true. Our University hospital gets a little less than 15k a year but a majority of them are complex resections, challenging biopsies and consult cases. To properly determine if 15k is enough, you need to know what sort of specimens they are and how many of them are consult cases.

 

[SpinachPizza]

I wouldn't count numbers of consults towards the total number of surgicals unless you know that you will get to look at them. At most places, faculty and (sometimes) fellows get the consults.

 

[yaah]

My program is nearly at 40k surgicals so far. That doesn't include consults. So there. 😛 It doesn't matter a TON if your program has less than 15-20k surgicals. Bear in mind that many of these programs have multiple facilties, each with different numbering systems. Plus, residents may rotate among different places. So a solo hospital with 5 residents per year and 15000 specimens is a lot different than a program that has multiple sites, 3 residents per year, and 15000 specimens. Some people have gone so far as to quantify the "Number of specimens per resident per year" or some such ratio. Some places with low specimen numbers will be busy.

It's all a rich tapestry. You can't go by numbers alone, but the number does tell you something about the volume of the program. As with everything else, take it with a grain of salt. Ask questions, look around.

 

[manicguacamole]

Hey, I really appreciate everybody's input on this one. I'd been away from a computer over the last weekend and haven't been able to thank you guys. It's a difficult decision for me, I think right now family is winning out. There do seem to be a good number of complex cases here, so I'm sure I'll see a good bit of variety. I'm sure it's not the best program in the world, but sometimes other things are more important. I really do appreciate hearing everyone's thoughts. Thanks a lot.

 

[Doctor B.]

I wouldn't count numbers of consults towards the total number of surgicals unless you know that you will get to look at them. At most places, faculty and (sometimes) fellows get the consults.

Good point.

Hey, I really appreciate everybody's input on this one. I'd been away from a computer over the last weekend and haven't been able to thank you guys. It's a difficult decision for me, I think right now family is winning out. There do seem to be a good number of complex cases here, so I'm sure I'll see a good bit of variety. I'm sure it's not the best program in the world, but sometimes other things are more important. I really do appreciate hearing everyone's thoughts. Thanks a lot.

I agree with you. My decision was based more on personal factors (friends and family) but I made sure I wasn't at an awful place either. If you think you will get adequate training and it satisfies your personal goals, go for it.