Unopposed residencies, have they gotten worse overall?

[MedicineZ0Z]

In theory, unopposed programs should be strong and give you more procedural opportunities among other things. But from my interview experiences last year and half a dozen friends' experiences... here were some things that came up and I'll divide them into 2 sections.

Small community and/or rural hospitals
- low volume, small census ("2 interns had to share a patient once")
- limited pathology in some cases
- ICU level patients are typically managed on the floor in big centers

Larger community hospitals
- Inpatient procedures done by IR and other consult services
- Midlevels have a big role on every rotation and may virtually be supervising you on several! rotations
- Not necessarily given the opportunity to do things in the ED as staff simply may not want a temporary trainee doing too much

On both sides: Limited autonomy on off-service rotations (of course this would be highly variable from rotation to rotation) + rotations where you're effectively shadowing. Midlevel dominance once on specialty rotations. And again, very strangely - limited procedural opportunities even when there are no other residents on the service. This one can vary again, but seems like the ED in particular likes to be hands-off increasingly in many places. Though this still puzzles me??

Now I do recognize that the best FM residencies are unopposed ones and that's often due to a general hospital culture among other factors. Any thoughts?

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[VA Hopeful Dr]

Crappy programs are crappy independent of opposed or unopposed.

 

[MedicineZ0Z]

Crappy programs are crappy independent of opposed or unopposed.

These were supposed to be pretty decent programs.

 

[septoplasty]

In theory, unopposed programs should be strong and give you more procedural opportunities among other things. But from my interview experiences last year and half a dozen friends' experiences... here were some things that came up and I'll divide them into 2 sections.

Small community and/or rural hospitals
- low volume, small census ("2 interns had to share a patient once")
- limited pathology in some cases
- ICU level patients are typically managed on the floor in big centers

Larger community hospitals
- Inpatient procedures done by IR and other consult services
- Midlevels have a big role on every rotation and may virtually be supervising you on several! rotations
- Not necessarily given the opportunity to do things in the ED as staff simply may not want a temporary trainee doing too much

On both sides: Limited autonomy on off-service rotations (of course this would be highly variable from rotation to rotation) + rotations where you're effectively shadowing. Midlevel dominance once on specialty rotations. And again, very strangely - limited procedural opportunities even when there are no other residents on the service. This one can vary again, but seems like the ED in particular likes to be hands-off increasingly in many places. Though this still puzzles me??

Now I do recognize that the best FM residencies are unopposed ones and that's often due to a general hospital culture among other factors. Any thoughts?

Sounds like you've know what to look for in good programs!

Also, per acgme rules, you cannot be supervised by a mid-level. That's a violation.

 

[MedicineZ0Z]

Sounds like you've know what to look for in good programs!

Also, per acgme rules, you cannot be supervised by a mid-level. That's a violation.

In reality, residents are very often supervised by midlevels (when off service). Attending signs the charts, has their name on everything and is supervising in an indirect way - but day to day tasks are done under a midlevel. It's been a booming issue nationwide and spans to many specialties. Off-service rotations for generalist specialties are a big one, others include the NICU etc where NP/PA presence is dominant overall.

 

[deleted87716]

In reality, residents are very often supervised by midlevels (when off service). Attending signs the charts, has their name on everything and is supervising in an indirect way - but day to day tasks are done under a midlevel.

SRSLY, y'all need to take a hard line with this. If they're a midlevel (PA, NP), it doesn't matter how long they've been around. When you graduate from medical school, your degree trumps theirs. They can't order you to do sh-t. If your program says otherwise, report them to the AGCME. The midlevels may report to the same attending that you report to, but that doesn't mean that you report to them.

 

[SLC]

My program was initially mostly unopposed, as we had our own hospital for Surgery,
Medicine, ICU, OB etc. We only joined other residencies for peds experience.

Then our hospital was shut down due to insolvency; and we did medicine and ICU with the IM program (we had our own FM medicine service, but our community patients were admitted with IM attendings and the FM clinic patients with our own faculty). We were the Gyn consultants for that hospital too.

We did OB at a women’s center with the university’s OBGyn residency; they were elite, and the personalities we had to deal with sucked, but we got better pathology and saw way more patients by virtue of working OB triage shifts while the OB residents were doing GynSurgeries. It sucked at times (most of them actually), but we learned our stuff. And I saved those OB residents asses more times than I can recall than as a medicine consultant.

we moved our ED experience down to another hospital that had an AOA EM residency. It was a good upgrade I’m told, I’d finished my EM shifts by then.

All told, I learned a ton working with other residents, and while my program was already one of the oldest and most respected programs out there when I got there; I can definitely say it’s way stronger training now than it was when I started. The medicine upgrade alone was HUGE!!!

then I’ve worked with FM docs who went to procedure heavy unopposed places and got sorta weak training in general. Sure they can operate a colonoscope, but they can’t titrate insulin or tell a viral respiratory illness in a 1yr old from an Otitis Media. in other words, they aren’t great at actual family medicine.

I think you have to be open to any program and judge it on its own merits. Unopposed is a weak metric IMO.

 

[linguistafeliz]

I just graduated from an unopposed program and didn't have that experience at all.

- Took care of my own ICU patients in open ICU
- Tons of scope (EGD/colonoscopy) exposure
- Strong L&D experience with multiple graduates now doing C sections
- Doing our own paracenteses, thoracenteses
- Not working with midlevels

Can say more in a private message if desired. Just my two cents.

 

[MedicineZ0Z]

I just graduated from an unopposed program and didn't have that experience at all.

- Took care of my own ICU patients in open ICU
- Tons of scope (EGD/colonoscopy) exposure
- Strong L&D experience with multiple graduates now doing C sections
- Doing our own paracenteses, thoracenteses
- Not working with midlevels

Can say more in a private message if desired. Just my two cents.

How was the high acuity exposure?

 

[aafisahar]

How was the high acuity exposure?

They didn't transfer afib with rvr out.

 

[SLC]

They didn't transfer afib with rvr out.

does any hospital ever do that?

 

[Splenda88]

Why would an hospital transfer afib with rvr out? I was doing night float as a PGY2 and admitted a few patients with new onset of afib with rvr... Every FM/IM resident should be able to take care of these patients

 

[linguistafeliz]

Good high acuity exposure. Took care of very sick patients in open ICU.

 

[aafisahar]

does any hospital ever do that?

The FM program in the boonies did this because they "didn't have cardiology on the weekends".

 

[SLC]

The FM program in the boonies did this because they "didn't have cardiology on the weekends".

Weak. We usually didn’t consult cards for this, unless it was refractory to our initial treatment. And patients could transfer out for that if it happened on a weekend when cards “wasn’t available”

 

[galactus]

I just graduated from an unopposed program and didn't have that experience at all.

- Took care of my own ICU patients in open ICU
- Tons of scope (EGD/colonoscopy) exposure
- Strong L&D experience with multiple graduates now doing C sections
- Doing our own paracenteses, thoracenteses
- Not working with midlevels

Can say more in a private message if desired. Just my two cents.

I had the same experience, but I was trained in an opposed residency. Academic hospital attached to the medical school.

I agree with the previous poster about opposed/unopposed really shouldn’t be a metric. I’ve seen really good opposed programs, and I’ve seen terrible unopposed programs that unfortunately and eventually closed.

 

[goldsummer]

Personal preference matters too... For me, I did not choose an unopposed program because I didn't have any desire to do all the inpatient procedures and also didn't really care about inpatient experiences in general as much. I prefer the bigger centers where FM sort of gets "lost in the mix" type of place and glady let the subspecialties, fellows do all the procedures... The only place I care about being unopposed is the clinic, since that's the only thing I wanna do...

 

[MedicineZ0Z]

Personal preference matters too... For me, I did not choose an unopposed program because I didn't have any desire to do all the inpatient procedures and also didn't really care about inpatient experiences in general as much. I prefer the bigger centers where FM sort of gets "lost in the mix" type of place and glady let the subspecialties, fellows do all the procedures... The only place I care about being unopposed is the clinic, since that's the only thing I wanna do...

I'm at an academic center and have done lots of procedures when off-service. Yet we have every single subspecialty possible.

I do think it's important for an FM inpatient service to do their own procedures rather than consult IR. Whether it's academic or community... Paras, thoras, LPs whatever - you should be doing your own procedures for patients on your service. Now in the ICU, it should be residents who will actually do them post residency. In my case, I'll be doing clinic and open-ICU inpatient medicine and hence procedural competency is very important. As is indepth knowledge which academic centers may provide more of.

 

[TableMD]

perfectly fine to not want to work in a hospital long term, but there is a value to exposure and learning bed side inpatient procedures.

You never know what you will want to do down the road.