Proactiv

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Hey guys. I was wondering if anyone can tell me about the advantages and disadvantages of an unopposed FM residency program? Is it better to go to a more established program?

Would also appreciate any advice on how to rank FM programs other than location. Thank you.
 

BobbyKoch

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so I'm sure people more knowledgeable will clarify this, but I heard in an open house with FM program directors that some people don't like the "opposed vs unopposed" terminology. they suggested, when reaching out to a program, to avoid that language and instead just ask directly if there are other residencies on-site or something to that effect. I have no idea what the big deal is I'm just relating what I heard (after asking essentially the same question you posed above). maybe it is nonsense.

otherwise, a major distinguishing factor I've noticed is whether the program is full-spectrum or not and, more generally, what patient populations do they serve? basically, do you want to have exposure to peds and OB? Do you want to be confident with women's health? or do you plan to practice in a more urban area/hospitalist setting with easy access to pediatricians and OB/Gyn? the program directors at the open house suggested asking about how many deliveries residents attend on average (or asking the residents directly during the interview day) to get a sense of how much OB exposure they get. another point that came up was to ask about how many residents have children/families themselves to help gauge how supportive the program is toward trainees pursuing their own family, if that is at all important to you.

I'll be curious to read what others who are further along in the process have to say. @SLC ?
 

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Unopposed = no other residents to share call with you = most brutal schedule. Nothing else is THAT different between the two, despite what PDs might try to say.

Source: am current 4th year going through interviews.
 
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Unopposed = no other residents to share call with you = most brutal schedule. Nothing else is THAT different between the two, despite what PDs might try to say.

Source: am current 4th year going through interviews.
I'm sure my experience isn't universally true, but that has not been my experience. I went to an unopposed program but did med school at an academic hospital and my wife did residency at a large community hospital.

Two main differences I saw were:

1. Opposed places have you rotate with other services frequently. At my program, outside of private patients we were the on-call OBs. Opposed places you rotate with the OB/GYN residents. This can be good or bad depending on how they treat other residents (EM gets included in that as well). Same with inpatient medicine and IM residents.

2. Opposed programs will almost certainly give you more exposure to rare pathology. There's a healthy argument to be made about which will serve you better in the long run: seeing more really uncommon stuff or seeing a higher volume of common stuff.
 
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Dr. Rafiki

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I'm sure my experience isn't universally true, but that has not been my experience. I went to an unopposed program but did med school at an academic hospital and my wife did residency at a large community hospital.

Two main differences I saw were:

1. Opposed places have you rotate with other services frequently. At my program, outside of private patients we were the on-call OBs. Opposed places you rotate with the OB/GYN residents. This can be good or bad depending on how they treat other residents (EM gets included in that as well). Same with inpatient medicine and IM residents.

2. Opposed programs will almost certainly give you more exposure to rare pathology. There's a healthy argument to be made about which will serve you better in the long run: seeing more really uncommon stuff or seeing a higher volume of common stuff.
Almost all opposed FM programs have their own inpatient service. In fact, of the 150 that I thoroughly researched, only one did not. The "rare pathology" trope simply doesn't hold water these days.

Your point of being the on-call OB service sort of proves my point. Unopposed = brutal hours and expectations. If you want to do rural FM with frequent C-sections, then yeah that's important. But at that point I'm unsure why you chose FM rather than OB.....
 

VA Hopeful Dr

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Almost all opposed FM programs have their own inpatient service. In fact, of the 150 that I thoroughly researched, only one did not. The "rare pathology" trope simply doesn't hold water these days.

Your point of being the on-call OB service sort of proves my point. Unopposed = brutal hours and expectations. If you want to do rural FM with frequent C-sections, then yeah that's important. But at that point I'm unsure why you chose FM rather than OB.....
Yes they have their own service but it's not always where they exclusively work. FM residents at the nearest academic center to me spend half of their inpatient time on the IM service and half on the FM service. The next nearest place that has an IM program (it just started) is planning to divide the FM residents' inpatient time as well.

What exactly do you mean "the rare pathology trope" doesn't hold water these days?

I'm not sure you understand how call works. It doesn't matter if you're on the OB resident team or the FM resident team, if you're covering L&D you're there the same number of hours because there has to be someone there 24/7 and we all have the same work hour restrictions. The main difference is in how you're treated as an FM resident. Historically, off-service rotators are the low person on the totem pole. Maybe that's changed in the last 6 years, but I kinda doubt it.
 
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SLC

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So I went to what I’d call a “semi-opposed” program, that became an “opposed” program. Though I think that term has obvious negative connotations that don’t automatically apply to residency programs that aren’t “unopposed”.

Where I went, we had a hospital where we were the main residents. There was an FMG IM shop there, they were solid residents, but we ran the hospital. We had our own services, there were 4 total medicine teams, 2 FM and 2 IM. The FM teams were different in that one team was attended by an FM attending from our continuity clinic; while the other team had hospitalist attendings. Those hospitalist attendings also attended the IM team’s, but not at the same time they attended the FM team.

There were some Podiatry residents as well, but they were useless and never actually around. They may have covered other hospitals too. That was it for residents.

But we rotated off site for Peds and we’re embedded with the pediatric interns at the children’s hospital. We also rotated with them for NICU. Other than that, we were a stand-alone program. The training was solid, we learned well.

then our hospital went belly-up and the program had to scatter us across multiple facilities to get everything done. Our new spot for hospital medicine was actually a stronger hospital. It was a satellite location for the main IM program (the one filled with US grads from high ranking schools). They had like 20 residents per class, and 8 at a time were at this hospital. They also did the ICU at this place, as did we.

But we (FM) had such great experience from the other place that we sorta took over that hospital too. Before long FM was its own teaching service, and they’d give us the same acuity they were giving the IM residents. We weren’t just folded into the IM teams, we were our own entity. By this point I was in my second year, and when I was on at night it would be me and an Intern and that’s it.

Pretty soon at this hospital, we became the defacto GYN consult service, we rotated in surgery (with the surgery residents). We got good training and saw more pathology because this new hospital was better equipped to care for sicker people. It was also larger.

we moved our OB service to the women’s hospital, which was owned by our original hospital’s parent company. That was an unmitigated disaster. The hospital was a joke, the OB residents were evil, the OB faculty was as well. They were being bossed around by CNM’s and those CNM’s didn’t like that we had actual medical knowledge when sick expectant mothers ended up in OB triage. But before long, we just carved out our own little niche and left the OB’s to destroy themselves with toxicity. I started moonlighting as a medicine consultant there, and I’d like to think it helped the OB residents realize that we were more utilitarian than they were. We could manage the obstetrics just as well (if not better) than they could. They certainly had surgical skills we didn’t, none of us were doing hyster’s or Gyn-Onc surgeries for example. But we (myself and the few other FM guys that eventually started moonlighting with me) bailed them out right and left when they had complicated medical patients because they didn’t know anything about managing illness that didn’t involve the Female Repro system. Even a few cases that did, they needed a bail-out. I remember advising them to image a woman who they thought had a bartholin cyst; but I could smell the necrosis from the doorway, and she was a poorly controlled diabetic. It was totally necrotizing fasciitis, and the woman nearly died. She’d been admitted the night before, placed on oral bactrim, and had an OR booked for a cyst drainage and marsupialization. They actually consulted me for pre-op clearance.

Anyway, I experienced both models; and I can confidently say that if you end up in a strong program, you end up in a strong program. I’ve seen people from “unopposed” places who are downright terrible, and the “unopposed” mantra is a dangerous think to rely 100% on. It doesn’t absolutely mean “quality training”.
 
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IntheClouds4ever

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I love being at a rural unopposed program. Interns take night shift 2 months out of the year (4weeks straight then again a few months later) so “call” isn’t terrible. (Also 5-6 weekends per year)
In your less intensive rotations, you can freely roam the ED and hospital to help out other residents, pick up procedures, etc.. a few months into intern year and I have countless intubations, ~15 central lines (ij and femoral), 3 chest tubes and numerous other procedures through clinic and ED.
If you can find a good program that supports those with a gung-ho initiative, I think you’re better off. However, unopposed vs opposed won’t matter much if you are micromanaged by PD that doesn’t give you a decent leash to push your experience and comfort levels or doesn’t allow any individual/self directed learning. we have some upper levels switching up there electives to do a sole Covid icu rotation to get better at vent modes such as aprv instead of relying solely on CMV and SIMV and other therapies.
 
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ciestar

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Yes they have their own service but it's not always where they exclusively work. FM residents at the nearest academic center to me spend half of their inpatient time on the IM service and half on the FM service. The next nearest place that has an IM program (it just started) is planning to divide the FM residents' inpatient time as well.

What exactly do you mean "the rare pathology trope" doesn't hold water these days?

I'm not sure you understand how call works. It doesn't matter if you're on the OB resident team or the FM resident team, if you're covering L&D you're there the same number of hours because there has to be someone there 24/7 and we all have the same work hour restrictions. The main difference is in how you're treated as an FM resident. Historically, off-service rotators are the low person on the totem pole. Maybe that's changed in the last 6 years, but I kinda doubt it.
It has not changed
 
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hallowmann

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This varies wildly from program to program. I've encountered very weak unopposed and opposed programs, and very strong opposed and unopposed programs. If you are interested in ICU management, I would look at unopposed programs with open ICUs, but the acuity is often lower in those ICUs, so it really depends on what you want.

To give you an idea, a hospital I rotated at in 4th year would put anyone on a diltiazem drip or insulin drip in an ICU, and they would often transfer out any STEMIs to a referral center. They had an unopposed FM program. The categorical FM program here in a huge opposed tertiary medical center will have those patients regularly on the floor and manage NSTEMIs and STEMIs all the time with heparin drip and Cards consults mainly for caths. I also encountered some opposed programs that would unevenly divide admissions between FM and IM, with the FM often getting the less complicated patients with 1-2 problems (e.g. CHF or COPD or CAP or cellulitis) and the IM team getting the more complex patients. Again, compared to the FM program here that manages all FM patients no matter how complex on their standalone service where their census consists of any patient with an FM PCP.

It really does vary wildly. You just need to figure out your own priorities in education, and find programs that fit that.
 
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