Thoughts about programs with 6 vs 12 vs 30+ residents

[Please_Stand_By]

Can anyone comment on the differences between having many residents per class vs only a few?

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[visari]

The size of the class usually reflects the size of the institution. I don't know of a program with 6 residents but a lot of community programs run in the 10-20 per class range. most academic places run in the 20-40 range. There are exceptions on both sides. Only a handful of programs go +40. I wouldn't make much of the size of the class but I would pay attention to the number of sites you will be working at. Usually places with +35 residents have multiple sites and some times these are scattered across town and it can be a pain in the *** driving around (LA for instance) and occasionally they will have different EMRs and systems all together. Not that it's a deal breaker if you really like the program but something to keep in mind.

 

[235009]

I went to a big program (top 30 in terms of size according to doximity) and I thought it was great. Keep in mind that typically the smaller the program the more nights you have to do, the more weekends you have to cover and the less flexible your schedule is for swaps or coverage.


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[DaTruMD]

I went to a big program (top 30 in terms of size according to doximity) and I thought it was great. Keep in mind that typically the smaller the program the more nights you have to do, the more weekends you have to cover and the less flexible your schedule is for swaps or coverage.


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Never thought about it that way. Thanks.

 

[gutonc]

Can anyone comment on the differences between having many residents per class vs only a few?

The small ones are smaller, while the big ones are bigger.

TBH, it's unlikely that anyone here has been at both a small and a large program.

The obvious issues are fewer people to help with coverage, and probably fewer outpatient/elective months.

That said, I was a resident at a University place with 30-35/y and am a sub-specialty attending (that has residents on our service) at a 10-15/y community place and, honestly, with the exceptions of research opportunities and patient population differences, there doesn't seem to be all that much different between the two overall. The Uni place had a more even spread of inpatient/outpatient over the 3 years while the place I am now is almost exclusively inpatient as an intern, almost exclusively outpatient/consult as an R2 and an even mix as an R3. The residents at both places (in the same city) seem equally (un)happy.

WRT doing more nights and call months, the work hour and IM RRC rules are universal. The community place has roughly 2x the non-teaching attendings that the University has, even for a slightly lower patient volume.

 

[nlax30]

I did my IM training at a small, community place with about 10 residents a year, a single fellowship and no other programs (unopposed IM). I'll echo what was said above in that it'll be hard to get definitive feedback unless someone has training at both type of programs.

In general though....

Small programs:
-If unopposed then maybe there are more opportunities for direct hands on/procedures (I got all the intubations, lines, etc... that I could have wanted), especially if you're the only residents covering codes/rapids in the hospital
-Possibility of program being a little more flexible to changes, though this is probably highly variable depending on the culture of the institution/hospital
-Likely won't have the sort of academic support as a larger program would such as a research coordinator, lots of residents/fellows in other programs to learn from, etc...
-Less residents so may be harder to fly under the radar (could be a good or bad thing)

Large programs:
-More residents so may be easier to fly under the radar (again, could be good or bad)
-Likely will have much more academic support with other teaching programs/departments and research support
-Likely will be having to battle other residents/fellows for certain procedures (again, depends on how things are structured there)
-May have some exposure to more "rare" pathology if at a tertiary care center (though I've seen plenty of plenty at my little community shop and this is probably more important more certain fields such as surgery/surgical subspecialities and some medicine sub-specialities and less important for general IM/FM.

So that's just a few thoughts off the top of my head.

 

[Trogghunter]

For my 0.02. I did 3rd and 4th year of med school at a community-academic hospital that took 8 per year and I'm at a program that takes 30, and for residency im telling you that it's all about exposure and volume. Not to incite a war on small vs big programs, but you're just not going to get equivalent training at a non referral center. If your patient volume and community diversity are good at a bfe community program then by all means go there, but if a big academic center is across town, don't bother if you're trying to get good training. At small community, youll rely on whatever is in the community and you'll see some zebras-few- but you won't know how to diagnose or treat anything outside of bread and butter bc you've only read about it. Your ICUs at community x are small and I'd argue that the stepdown patients at my program now are mostly sicker than the icu patients from med school. Surw, you're the only one covering but you usually have less supervision and sometimes paper charts. Also, you really shouldn't be intubating as an internist. You don't really need that many procedures to be good enough ie I have over 50 central lines logged but feel as comfortable as I did at 10, I also have 10 thoracentesis but still don't feel comfortable. After 2 months, you'll probably want to avoid most procedures anyway bc they impede work flow. We do have a lot of residents, but we also get referrals from 25+ hospitals and like 40k admissions per year. Don't believe anyone when they tell you that your procedures will be stolen, we do so many that we had to start a procedure service and they're still to busy. Bottom line, find somewhere with lots of sick patients and a good schedule.

 

[agranulocytosis]

For my 0.02. I did 3rd and 4th year of med school at a community-academic hospital that took 8 per year and I'm at a program that takes 30, and for residency im telling you that it's all about exposure and volume. Not to incite a war on small vs big programs, but you're just not going to get equivalent training at a non referral center. If your patient volume and community diversity are good at a bfe community program then by all means go there, but if a big academic center is across town, don't bother if you're trying to get good training. At small community, youll rely on whatever is in the community and you'll see some zebras-few- but you won't know how to diagnose or treat anything outside of bread and butter bc you've only read about it. Your ICUs at community x are small and I'd argue that the stepdown patients at my program now are mostly sicker than the icu patients from med school. Surw, you're the only one covering but you usually have less supervision and sometimes paper charts. Also, you really shouldn't be intubating as an internist. You don't really need that many procedures to be good enough ie I have over 50 central lines logged but feel as comfortable as I did at 10, I also have 10 thoracentesis but still don't feel comfortable. After 2 months, you'll probably want to avoid most procedures anyway bc they impede work flow. We do have a lot of residents, but we also get referrals from 25+ hospitals and like 40k admissions per year. Don't believe anyone when they tell you that your procedures will be stolen, we do so many that we had to start a procedure service and they're still to busy. Bottom line, find somewhere with lots of sick patients and a good schedule.

My 0.02. I did my 3 years of IM training at a community IM program of about 12 per year. Hospital was a community hospital, but it was a tertiary referral center, 1,100-bed hospital. You can't generalize everything.

 

[gutonc]

My 0.02. I did my 3 years of IM training at a community IM program of about 12 per year. Hospital was a community hospital, but it was a tertiary referral center, 1,100-bed hospital. You can't generalize everything.

I was going to say the same thing.

My University IM program (the only one in the state) was at a quarternary referral center with ~560 beds. We had 30-ish residents/year. The next largest program in town was at the other Level 1 trauma center in the state, a tertiary referral center, with 2 hospitals about 1 mile apart from each other. 12-ish IM residents/year and nearly 1100 beds between the two hospitals.

I work with those residents now and have seen as much, if not more, crazy s*** coming out of there than I did the ivory tower 3 miles away where I did my training.

You can't generalize.

 

[Trogghunter]

My bad, what I mean is that you need volume. If your program is 8 a year with 250 beds like xyz community regional vs something like Inova Fairfax or Christianna with 100 beds ~8 residents a year, then you'll probably get good training there/see some things, but if youre referring everything out then that's not a good place to train.

 

[DaTruMD]

My bad, what I mean is that you need volume. If your program is 8 a year with 250 beds like xyz community regional vs something like Inova Fairfax or Christianna with 100 beds ~8 residents a year, then you'll probably get good training there/see some things, but if youre referring everything out then that's not a good place to train.

Do you mean 1,000 beds?

 

[Siggy]

I did a transitional year at a 450 bed county hospital (15/year give or take) and am not at a 250 bed community that is 6/year. As was already said, we get a fair amount of pathology for a small hospital and we really don't refer out very much. On one hand, I'm not likely to see some of the crazy referral patients that end up at County. We also don't have the level of rapid responses and codes that county had...

On the other hand, I get tapped for any and all bedside procedures because there's no competition (placed a pig tail chest tube yesterday, multiple intubations, and central lines already this year) when compared to a county hospital with IM, FM, surgery, neurosurgery, EM, OB residencies and a critical care fellowship. Also, county had 5 medicine teaching teams, 2 hospitalist teams, and an ICU team (essentially a closed ICU for medicine), so there was a good chance that I might not get to see the crazy zebra that occasionally pops up. Whereas at community, there's one team, so I'm much more likely to get the post partum cardiomyopathy or the methanol OD than I would be at County.

 

[copperpenny189]

For my 0.02. I did 3rd and 4th year of med school at a community-academic hospital that took 8 per year and I'm at a program that takes 30, and for residency im telling you that it's all about exposure and volume. Not to incite a war on small vs big programs, but you're just not going to get equivalent training at a non referral center. If your patient volume and community diversity are good at a bfe community program then by all means go there, but if a big academic center is across town, don't bother if you're trying to get good training. At small community, youll rely on whatever is in the community and you'll see some zebras-few- but you won't know how to diagnose or treat anything outside of bread and butter bc you've only read about it. Your ICUs at community x are small and I'd argue that the stepdown patients at my program now are mostly sicker than the icu patients from med school. Surw, you're the only one covering but you usually have less supervision and sometimes paper charts. Also, you really shouldn't be intubating as an internist. You don't really need that many procedures to be good enough ie I have over 50 central lines logged but feel as comfortable as I did at 10, I also have 10 thoracentesis but still don't feel comfortable. After 2 months, you'll probably want to avoid most procedures anyway bc they impede work flow. We do have a lot of residents, but we also get referrals from 25+ hospitals and like 40k admissions per year. Don't believe anyone when they tell you that your procedures will be stolen, we do so many that we had to start a procedure service and they're still to busy. Bottom line, find somewhere with lots of sick patients and a good schedule.

Couldn't agree more with this statement. In a similar boat and I have similar observations.

 

[InvestingDoc]

Just because you go to a large program does not equal less call potentially. This is a misconception that I actually had early on going into my residency program.

I went to a program with over 50 residents a year that now serves 4 hospitals. Even on my ambulatory months I had to take overnight call in the hospital. I would go to clinic and then after 5 be required to go to the hospital and be on call overnight. We only had one call free month per year which was kind of rough after 3 years. I averaged 2-3 calls per month (worst month I had 5 calls) when not on a call heavy month such as neuro, ICU or other rotation such as pulm where it was basically an ICU rotation and we did q3 or q4 call.

At my residency program I also assumed that neuro would take stroke call...not the case. Medicine residents took stroke call just like the neuro residents. Nothing will make your feel like you're going into a SVT quicker than a stroke alert where you are evaluating and calling attending deciding to give tpa or not. I HATED that so much since I'm not a darn neurologist.

 

[justin1390]

Just because you go to a large program does not equal less call potentially. This is a misconception that I actually had early on going into my residency program.

I went to a program with over 50 residents a year that now serves 4 hospitals. Even on my ambulatory months I had to take overnight call in the hospital. I would go to clinic and then after 5 be required to go to the hospital and be on call overnight. We only had one call free month per year which was kind of rough after 3 years. I averaged 2-3 calls per month (worst month I had 5 calls) when not on a call heavy month such as neuro, ICU or other rotation such as pulm where it was basically an ICU rotation and we did q3 or q4 call.

At my residency program I also assumed that neuro would take stroke call...not the case. Medicine residents took stroke call just like the neuro residents. Nothing will make your feel like you're going into a SVT quicker than a stroke alert where you are evaluating and calling attending deciding to give tpa or not. I HATED that so much since I'm not a darn neurologist.

Agreed. I am at a 10/year residency at a large 900 bed hospital. We are basically the only residency here (there's family med, I suppose). We do not take 24hr call as interns. Seniors only have 24 hour call ~6x a year. We work on a block system with one month of night float. It's honestly pretty sweet, and most residents are pretty content here. We do everything up to neurosurgery 24/7. I'm 3 months in and signed off on paras, thoras, and central lines. We send 3-4 a year to fellowship.

That said, keep in mind that if one of us drops out or gets sick, that is a HUGE hit to the schedule. So even though we have 12 sick days, basically no one uses it unless you are retching over the toilet bowl...

 

[lenomegaly]

I just finished my residency at a program with 55 categorical residents/year. Overall I think having a big program has lots of positives.

Positives:
- Very very easy to find coverage when I had to go to weddings, etc.
- In the event someone has to take time-off for personal reasons (family death, pregnancy, etc) the impact is easily absorbed by a large program compared to a small one.
- Lots of different residents = lots different people to hang out with. If you are in a small program and don't like your 7 co-residents... that can be rough.
- There aren't situations (at least at my old program) where residents are burdened with a unmanageable workload... because the program can spread out the work. For example, the program can afford to put 5 residents on at night coverning only the ward teams and everyone has a very manageable workload. I've heard of programs where one resident cross cover several ICU teams overnight, while responding to codes on the floor, while doing any and all procedures overnight, while also admitting... etc etc (this is likely all very institution dependent)
- You have a much wider contact pool when you are applying for jobs/fellowship. The program has likely sent residents to nearly every local institution and make no mistake.... those old-residents can certainly help get you into new jobs or fellowships even if they have never met you. Personal contacts goes a long way when looking for what to do after residency.

Disadvantages:
- My concerns when I first joined were that it would be easy to get lost in such a large program, or that people would be competing for limited research opportunities. But it actually turned out to be quite the opposite. The bigger the institution, the more projects that existed. Plus I teamed up with several co-residents and we worked on a much more ambitious project that I probably wouldn't have been able to do solo if I had gone to a smaller program. Overall I think my concerns were unfounded and I would still pick a large program if I went back and did it all again.