top tier path programs

[flower12]

In a forum in 8/03, the "top tier" path programs were subjectively stated by one person to be the following, in no particular order:

Brigham
MGH
U Washington
Stanford
Mayo
UCLA
Emory
Duke
UTSW
UCSF

Overall I agree with this, but I think Hopkins should be added to this list.
I am wondering what the current thinking on this is...for instance, people rave about Michigan, UVA, Cleveland Clinic, Columbia, UNC, Pittsburgh and U Penn...

First of all, I am wondering what criteria people use when they consider "top tier" programs...reputation? research money? overall quality of the hospital? pathology publications?--because frankly, many of these criteria may not improve resident training. In fact, many (but definitely not all) of these so-called "top tier" programs are also said to be "malignant"--with insane work hours, endless scutwork, and a quality of life so poor that it borders on that of our clinical intern brethren. I know--duh!--but some newbies to the path forum may not be aware of these differences in quality of training.

It makes me wonder...what is the current thinking on these "top tier" programs? And which of these programs would be considered "benign" vs. "malignant"? Are more benign, "middle tier" programs gaining more respect based on quality of training rather than reputation--and what about the programs with a "big name" reputation?

I hear so many different ideas from everyone. But what the hey--let's hash it out--we may be able to offer insight at least to people who will be applying next year

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[yaah]

The reason you have doubts, which are valid, about that ranking is that the person who arbitrarily decided that those ten programs are the best is full of crap. Anyone who ranks programs in such a way is full of crap. If I remember this post right, there was also a comment that "it is generally agreed that this ranking is true." By who? Not anyone I have ever talked to.

Now, if you want to stratify programs based on certain things, that is perhaps more appropriate.

The best programs if you want to be an academic researcher (MD/PhD type) with perhaps some clinical service time, but basically spending most of your time in a lab or writing papers are vastly different than if you are making a list based on programs that train you to be a good diagnostician. i.e., training at U Penn or Brigham will position you for a good academic job following residency but if you want to go into private practice you may find some of your skills to be deficient. Programs like MGH and Cleveland Clinic (and fellowships at JHU) are known for their high volume and good preparation for a diagnostic career, often in academics, where you have a career like Epstein or Weiss and don't do bench research but publish a lot and define the standards for diagnosis. Programs like Vermont and MUSC train very good community physicians. Does that mean that by picking a certain program you are mapping out your career path? NO!

Personally, there is no way, on my list, that I would rank Emory, Duke, UTSW, Mayo, Stanford, U Wash, and UCLA over most of the programs you listed next. Cleveland Clinic is a great program from what I have heard, although it has high volume and is sometimes hard to find your own way. Pittsburgh has a high number of fellowships but some say that for residency your training suffers as a result. Same with MGH. I really like the Michigan program because of the size, the history, and the great educators we have here who really care about resident education (Appelman, McKenna, Myers, Greenson, Schnitzer, Finn, Ramsburgh, Shah). U Penn completely turned me off when I was there because it seemed like they were marginalizing training in learning diagnostics. That is probably not everyone's impression. But it was mine, and so I ranked them 12th on my rank list.

As far as malignancy, one person's malignant is another's paradise. To some people, a malignant program is one where you spend all day in the hospital previewing slides and reading. To others, it is where you can't spend as much time with slides and have to spend too much time grossing or on the phone or whatever.

Others will rank programs not based on their experience there or what people tell them about the program, but on the hospital's reputation or what attendings work there. Like, "JHU is better because Kurman and Epstein are there," ignoring the fact that Kurman and Epstein work almost entirely with consults and their fellows.

You have to pick a program based on what you are looking for, your goals in training, etc. Not based on the arbitrary nature of someone else's rankings which are highly likely to be biased in some way. The list above, for example, I have no idea where that came from. It sounds to me as though it is someone who is either from the southeast or the west coast, and threw in Mayo because it's a famous program in the midwest, and threw in MGH and Brigham because everyone says they're good.

Now, I personally have opinions on almost all of the programs you listed there. Some are favorable (Michigan, MGH, UVA) whereas some are not (U Penn, Columbia, Mayo, Stanford) but a lot of this comes from the fact that some of the things I want out of a residency program are good teaching, emphasis on resident education, a respectful environment, and less of an emphasis on doing lots of research during your training.

 

[drPLUM]

No offense but I don't think people really like talking about this subject. Although, earlier in this match process I was dying to get anyone's opinion on it. I finally cam to the realization that there are no objective "top" programs, only those that someone's attending said was good, or somone saw a bunch of posts about being good. What makes it so hard as an applicant is that there are definitely programs that are better than others (and I don't mean "better for you" type of better), its just not as black and white as one might think.

For instance, most of those programs on that list are great, but as you pointed out they left off Hopkins which is also great. I interviewed recently at several of those places and some are not so great after you have been there. I really think you have to go there to get some perspective. For example, I had heard (on this board actually) some preposterous, rediculous rumors about Duke but I went there and loved it and thought they had intense faculty committment to resident education which was proven by their willingness to be flexible with workload demands (eg- no scut), protected preview time, and super conferences. In other words, you can't believe everything you hear, anywhere.

I think yaah has mentioned before that the best way to distinguish "top" programs is to open up a text book and see who wrote the chapters. I have to agree with this, only to add that one should go the places and see for themselves.

Oh and this post isn't directed at you inparticular, just my random thoughts.

 

[yaah]

Well said Drplum. I would also add that you can get vastly different impressions of a program simply by talking to two different residents at the same program. Like here, for example, there are residents who wish they went somewhere else because they feel the program isn't training them in a certain way, etc etc.

And in regards to your point about who wrote the chapters - that is an interesting point yet not always true. Like I mentioned above - if you go to JHU as a resident the only time you might see Kurman is in the hallway or perhaps if he gives a lecture. And some people, to be honest, who write textbook chapters are not good teachers.

I posted this before http://forums.studentdoctor.net/showthread.php?t=115367
Couple of links in there which link to others' opinions. You wil quickly find that the list of the "top 10" programs can easily grow to about 50 or 60 programs.

 

[CameronFrye]

The reason you have doubts, which are valid, about that ranking is that the person who arbitrarily decided that those ten programs are the best is full of crap. Anyone who ranks programs in such a way is full of crap. If I remember this post right, there was also a comment that "it is generally agreed that this ranking is true." By who? Not anyone I have ever talked to.

Now, if you want to stratify programs based on certain things, that is perhaps more appropriate.

The best programs if you want to be an academic researcher (MD/PhD type) with perhaps some clinical service time, but basically spending most of your time in a lab or writing papers are vastly different than if you are making a list based on programs that train you to be a good diagnostician. i.e., training at U Penn or Brigham will position you for a good academic job following residency but if you want to go into private practice you may find some of your skills to be deficient. Programs like MGH and Cleveland Clinic (and fellowships at JHU) are known for their high volume and good preparation for a diagnostic career, often in academics, where you have a career like Epstein or Weiss and don't do bench research but publish a lot and define the standards for diagnosis. Programs like Vermont and MUSC train very good community physicians. Does that mean that by picking a certain program you are mapping out your career path? NO!

Personally, there is no way, on my list, that I would rank Emory, Duke, UTSW, Mayo, Stanford, U Wash, and UCLA over most of the programs you listed next. Cleveland Clinic is a great program from what I have heard, although it has high volume and is sometimes hard to find your own way. Pittsburgh has a high number of fellowships but some say that for residency your training suffers as a result. Same with MGH. I really like the Michigan program because of the size, the history, and the great educators we have here who really care about resident education (Appelman, McKenna, Myers, Greenson, Schnitzer, Finn, Ramsburgh, Shah). U Penn completely turned me off when I was there because it seemed like they were marginalizing training in learning diagnostics. That is probably not everyone's impression. But it was mine, and so I ranked them 12th on my rank list.

As far as malignancy, one person's malignant is another's paradise. To some people, a malignant program is one where you spend all day in the hospital previewing slides and reading. To others, it is where you can't spend as much time with slides and have to spend too much time grossing or on the phone or whatever.

Others will rank programs not based on their experience there or what people tell them about the program, but on the hospital's reputation or what attendings work there. Like, "JHU is better because Kurman and Epstein are there," ignoring the fact that Kurman and Epstein work almost entirely with consults and their fellows.

You have to pick a program based on what you are looking for, your goals in training, etc. Not based on the arbitrary nature of someone else's rankings which are highly likely to be biased in some way. The list above, for example, I have no idea where that came from. It sounds to me as though it is someone who is either from the southeast or the west coast, and threw in Mayo because it's a famous program in the midwest, and threw in MGH and Brigham because everyone says they're good.

Now, I personally have opinions on almost all of the programs you listed there. Some are favorable (Michigan, MGH, UVA) whereas some are not (U Penn, Columbia, Mayo, Stanford) but a lot of this comes from the fact that some of the things I want out of a residency program are good teaching, emphasis on resident education, a respectful environment, and less of an emphasis on doing lots of research during your training.

I agree (well, except for your comment about Emory. I found Emory to be very similar to places like Michigan and UVA when it came to good diagnostic training and a focus on resident education. Pretty much all the path big wigs I've talked to also have good things to say about Emory).

Anyway, you really do need to figure out your own top 10 programs, b/c it really does vary greatly depending on who you talk to.

 

[AngryTesticle]

Although what people say about "top programs" are largely subjective, I would agree that all the places mentioned previously on this thread comprise the stronger pathology programs. Although there is some discomfort, since we don't want to offend people, in discussing what these top tier programs are, we cannot hide from this. There does seem to be some consensus as to what the stronger programs are and what the weaker programs are. I don't mean to sound pompous but that's just simple reality.

Each of these places have their fair share of world renowned experts in their respective fields. You're not going to find a place that has every expert in every field simply because these are heavily recruited people and they tend to move based on offers. Also, in line with what yaah said, these experts mainly deal with their own personal consults. For instance, we have Dr. Fletcher but he rarely signs out cases on the general surgical pathology side. He has his own soft tissue pathology signouts which happen every evening and we can attend if we want to. Of course, seating at his signouts are limited and there is a priority system as to who gets first dibs on sitting in. For instance, first year residents are near the bottom of the priority list. I've sat in on some of his signouts, mainly when I have a soft tissue case where we need to run it by him for his "blessing". Based on my limited experience, his service sees a lot of cool and weird cases from all over the world but I haven't sat in on his signout much.

Some programs are better geared for academic types and others are more geared for training general community practice diagnosticians. These two things don't have to be mutually exclusive though. If your institution has a high specimen volume and variety (and complexity), you will be well trained to tackle a lot of things that come your way when you eventually go out to practice. Also, keep in mind that at some places that have ridiculously high specimen numbers, some of the cases go straight to the attendings without resident involvement. People will jump to the conclusion that this is bad but let's be realistic, residents can't do EVERYTHING! There has to be some sense of practicality as to how cases are handled so that patient care can still be carried out effectively and efficiently. At our program, we're on the brink. Specimen volume and complexity is very high and continues to increase. However, we are cutting down the # of AP and AP/CP residents from 10 per year to 9. There is some discussion as to whether some cases will eventually go straight to the attendings. However, residents seem ambivalent on this matter since some of them (myself excluded) want to see every single case because they take diagnostic training extremely seriously. Dr. Fletcher, who is the head of general surg path here, isn't too enthusiastic about the possibility of compromising resident education by doing this either.

 

[miko2005]

Personally, there is no way, on my list, that I would rank Emory, Duke, UTSW, Mayo, Stanford, U Wash, and UCLA over most of the programs you listed next.

Yaah, I am just curious... Did you interview at all those places you listed (UWash, Stanford, UCLA), otherwise how do you know what they are like? I agree with Drplum, in that without actually seeing some of these places, we really shouldn't be saying anything negative about any programs. I realize that you were just stating your opinion, but it seems that sometimes opinions are only based on "rumors". I have definitely spoken to attendings who thought that those programs were top tier.

 

[DarksideAllstar]

Yaah, I am just curious... Did you interview at all those places you listed (UWash, Stanford, UCLA), otherwise how do you know what they are like? I agree with Drplum, in that without actually seeing some of these places, we really shouldn't be saying anything negative about any programs. I realize that you were just stating your opinion, but it seems that sometimes opinions are only based on "rumors". I have definitely spoken to attendings who thought that those programs were top tier.

I dont think that he said anything "negative" about those programs at all. He just said that his "ranking" would be different. Not everyone has to completely and utterly agree that Stanford offers great training or the UW is the place to be. To an extent, training is what you make of it, and I am sure that anyone motivated enough can suceed at most places. I am tired of hearing this argument over and over again about what places are "the best" or "top tier", particularly when its completely subjective. Sorry, this rant wasn't specifically directed at you.

 

[tsj]

Any busy large regional referral institution can give you a "top tier" experience. It doesn't matter if the people who write the textbooks are there as long as the surgical specimens are there. If the place is big it will have subspecialized people focused on the various specimens who will teach you the finer more subtle points about the cases even if they aren't THE AUTHORITY in the field.


If you want to do a fellowship in a specialty then it is probably a good idea to do a fellowship where the big names are (i.e. if you want to do soft tissue go to Emory or BWH, if you want to do liver go to a huge transplant center, etc...).

 

[yaah]

Yaah, I am just curious... Did you interview at all those places you listed (UWash, Stanford, UCLA), otherwise how do you know what they are like? I agree with Drplum, in that without actually seeing some of these places, we really shouldn't be saying anything negative about any programs. I realize that you were just stating your opinion, but it seems that sometimes opinions are only based on "rumors". I have definitely spoken to attendings who thought that those programs were top tier.

No, and see, as stated in a later post, this is why rankings are bull****. I know a bit about stanford because there were issues going on there during my residency interviews and I heard a lot about it (which is probably irrelevant now) and I know someone who did a fellowship there. And I know people who have gone through interviews or fellowships at UW and UCLA but I didn't interview there. I didn't interview on the west coast because I don't like the west coast and no program is worth living out there to me unless they were going to pay me triple my current salary for residency.

As I said, "top tier" includes about 50-60 programs. If anyone asks me to list them I cannot be responsible for my actions.

As I have also posted before - you learn in different ways. If a place is all subspecialty and every signout is run by a subspecialist sure you will learn a lot about details and the diseases. But you may not learn how to approach the case if you don't see a lot of them. If you get a myxofibrosarcoma with Goldblum he might say, "this is a myxofibrosarcoma and here are the features" etc etc, and you might say, "wow, great, I learned a ton." And that would be true. But if you see it with someone who sees one every three years you might learn differently but still get the right diagnosis. Perhaps it would make you think more and learn more that way. I vary and in the end like experiencing some of each. Last month I was on GYN path and spent one week with someone who only signs out gyn path. The next week I signed out with a cytologist and general surgical pathologist. Both were instructive.

It's frustrating to think that people develop lasting negative opinions (or falsely elevated opinions) of programs here based on one or two comments. Someone could post something innocuous and probably random like "I had a bad experience interviewing at program X and everyone seemed stressed that day" and then five months later there is a new thread here which starts off, "I have heard program X is malignant and everyone is stressed - is it still a good program?"

I cannot stress enough the importance of finding out about these programs yourself. Sure, listen to people's opinions, but take them with a grain of salt. If you hear mostly good things, wonder why they aren't telling you the negatives. If it's all bad, suspect that even more. If someone badmouths a particular program there is generally a specific reason why, and it most likely relates to a personal reason that doesn't apply to others.

 

[miko2005]

It's frustrating to think that people develop lasting negative opinions (or falsely elevated opinions) of programs here based on one or two comments. Someone could post something innocuous and probably random like "I had a bad experience interviewing at program X and everyone seemed stressed that day" and then five months later there is a new thread here which starts off, "I have heard program X is malignant and everyone is stressed - is it still a good program?"

I cannot stress enough the importance of finding out about these programs yourself.

Yaah, I definitely agree with that and that was my biggest point.

UCSFbound -- I never said "everyone has to completely and utterly agree that Stanford offers great training or the UW is the place to be". Seems like a personal attack on me, good thing I couldn't care less.

 

[yaah]

I never said "everyone has to completely and utterly agree that Stanford offers great training or the UW is the place to be".

But are they top tier?

 

[tsj]

Another good objective way to size up "top-tier" programs is if they have a lot of fellowships in boarded and non-boarded "subspecialties". If they have a fellowship in an area, you know two things. You know they have a lot of material in that area and they have an attending who is interested in it. If they have a GU fellow, you know you are going to get some quality GU material. If they have dermfellows, you can see plenty of skin. If they have a renal fellowship, you know they have a lot of medical kidney. If they have a chemistry fellow, you can see a lot of chemisty (wait...that's a bad thing). In general the more fellowships they offer, the more confident you can be that you have the opportunity to get exposed to a lot of pathology.

 

[miko2005]

But are they top tier?

Yes.

 

[yaah]

Another good objective way to size up "top-tier" programs is if they have a lot of fellowships in boarded and non-boarded "subspecialties". If they have a fellowship in an area, you know two things. You know they have a lot of material in that area and they have an attending who is interested in it. If they have a GU fellow, you know you are going to get some quality GU material. If they have dermfellows, you can see plenty of skin. If they have a renal fellowship, you know they have a lot of medical kidney. If they have a chemistry fellow, you can see a lot of chemisty (wait...that's a bad thing). In general the more fellowships they offer, the more confident you can be that you have the opportunity to get exposed to a lot of pathology.

This is a good point, but the wary candidate would be wise to pay attention on interviews in places with lots of fellowships, and ask whether residents actually see any of this variety. At some programs, the fellowships deal mainly with consults, and the residents rarely see any of this and deal mostly with day to day stuff, which may or may not be any different from another program. Just something to keep in mind...things are not always what they seem.

 

[DarksideAllstar]

Seems like a personal attack on me, good thing I couldn't care less.

I dont remember specifically quoting you regarding Stanford or UW, but if you want to hallucinate that I did, well, that's fine. And it seems like you do care, as you felt the need to respond to it in the first place . Good luck with the match.

 

[AngryTesticle]

This is a good point, but the wary candidate would be wise to pay attention on interviews in places with lots of fellowships, and ask whether residents actually see any of this variety. At some programs, the fellowships deal mainly with consults, and the residents rarely see any of this and deal mostly with day to day stuff, which may or may not be any different from another program. Just something to keep in mind...things are not always what they seem.

tsj and yaah make good points.

In my mind, the whole concept of residents seeing consults is way overrated. It seems that at most places, fellows are the ones that deal with the outside consults. Here, that is the case as well but consults from outside places fall into two categories:

(1) General consults - these are usually stupid cases that get dumped on residents so that the fellow can focus on the more important subspecialty consults which have to be signed out with a certain attending. The patients are coming to our hospital for surgery but was worked up on the outside. So we have to review the slides and issue our own report. These cases are on the bottom of my priority list.

(2) Subspecialty consults - various services get outside consult cases. Fellows mainly deal with them. Residents generally don't see them during the first two years.

 

[cytoborg]

This is a good point, but the wary candidate would be wise to pay attention on interviews in places with lots of fellowships, and ask whether residents actually see any of this variety. At some programs, the fellowships deal mainly with consults, and the residents rarely see any of this and deal mostly with day to day stuff, which may or may not be any different from another program. Just something to keep in mind...things are not always what they seem.

Word. Ask the residents, discreetly and tactfully, about the workflow and how the fellows fit into it. At higher volume centers, there may be plenty of cases to go around for everybody, so you don't have to worry about fellows taking the best/most interesting cases - you'll have plenty of your own. What might be more worrisome is a smaller-volume center that has many fellows. They may have "enough" specimens to qualify for a fellowship, but maybe not "enough" to share with the residnets...unless of course the residents are somehow able to see the same cases as the fellow...guess it just depends on the set-up of the workflow.