Why does a residency matter? and how to shape career

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docscience

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So just another naive question: Does it matter where you do your residency? and why? Do private practices care? Do hospitals care?

I understand that for competitive fellowships (for example in IM...GI, Cards) going to a big name residency helps secure the fellowship position.

I understand that it "looks good" if you go to Harvard, Mayo, etc. and one probably has access to better equipment, renowned faculty, and perhaps overall training..
But...the training is probably somewhat similar across the board right? I mean, you have to have certain competencies to pass/board certification. Right?

Thanks for the help again guys.
 
But...the training is probably somewhat similar across the board right? I mean, you have to have certain competencies to pass/board certification. Right?
Well, yeah. There has to be a baseline level of training, or they wouldn't be accredited.
 
Well, yeah. There has to be a baseline level of training, or they wouldn't be accredited.

True, then again, accreditation has so much to do with things like work hours and faculty-to-resident ratios, etc., etc. It's not hard for programs to maintain accreditation and still produce poor residents.

Paradoxically, programs that bend and break the rules that maintain their accreditation can produce great residents. Working over the 80-hour limit or not having proper staff supervision can help a competent resident to become more independent and confident in his or her decision making.

To the OP, the truth is that most practices don't care very much at all. As you've already mentioned, it matters for fellowship selection and it matters if you intend to practice in academic medicine.

Apart from that, the generic private practice group cares much more about your personality and your work ethic. They'll want you to be board certified, of course, but apart from that your academic pedigree is of relatively little importance.
 
For me, I'd rather do a residency in a normal place in a city I personally like where I can do stuff instead of a Harvard stamped place where people ignore you 90% of the time and half of your working hours are spent fetching people coffee.

As long as you pass the accredition test, that's what you'll need. It matter more that you work hard in the end. In Mexico most doctors don't even want to get near Academic medicine because it pays so bad, maybe things are different in the US.

They're not. But there are the "intangible benefits" of job satisfaction (provided you enjoy teaching, research, and administration- the three key responsibilities to be fulfilled in an academic position). Benefits are also usu. better.
 
The accreditation/board passage requirements are minimums. Just from med school experience we all know somebody who coasts by with 190s on their Steps is a whole host of knowledge poorer than someone nailing 250s. I think it's somewhat specialty-dependent but it's probably the same with residency; you'd be crazy to think there's not a difference in training between MGH internal med and BFE Alabama internal med even though both hit minimum accreditation, JCAHO inspection ratings, etc. I don't have much info on the private practice hiring other than regarding an ophtho practice where my wife was employed a few years ago. It's a job market like any other, and the guys from 'renowned' programs Bascom and Wills got more play just like a Harvard MBA would for some random management position in the corporate world.
 
For me, I'd rather do a residency in a normal place in a city I personally like where I can do stuff instead of a Harvard stamped place where people ignore you 90% of the time and half of your working hours are spent fetching people coffee.

As long as you pass the accredition test, that's what you'll need. It matter more that you work hard in the end. In Mexico most doctors don't even want to get near Academic medicine because it pays so bad, maybe things are different in the US.
"harvard stamped" places don't become well known for making their residents get coffee. They become well known by forcing their residents to be intelligent and independent in order to get the job done properly. They produce people that will be able to jump right into a practice and provide good results doing so.
 
I wouldn't be surprised it's similar in the US, but the really fancy posh slots have people that won't let any random guy treat them. That's where I put the part about fetch the coffee, keeps people busy. Posh places that are highly competitive for brand name purposes but don't give the same hands on experience stay accredited a lot because of all of the heavy research being done.

What you're describing really doesn't sound comparable to the US.

The top residency programs at "brand name" institutions take a ton of pride in their clinical training, and rightly so. They are at institutions with outstanding researchers and outstanding clinicians. They are at tertiary referral centers where the most complex/serious cases get sent from the smaller surrounding hospitals.

And often, the "top" programs aren't known for being "fancy, posh" but rather for working the residents' butts off. Look at the forums below on residency applications - Johns Hopkins medicine residency brags about how it is not for everyone and it is an extremely tough program - with lots of inpatient months and high expectations. MGH (the most well known "harvard branded" program) is similar in terms of having a tough reputation.
 
The one thing that ALWAYS gets overlooked in these types of conversations is location.

Where do you want to end up practicing?

Bottom line, there are only a few places that have a truly national name that's going to draw oohs and aahs. But the thing is most people dont' really need or want a national name to make their career what they want it to be. As the OP has already seen, there's often a strong case made for the locals. And even if you do eventually do decide to make some sort of major coastal shift, unless it's immediately after your residency or fellowship, then the issue is going to much more about what you've DONE than where you did it. Unless a place/group has had particularly poor run-ins with products of one specific program, it's likely to simply be a non-issue...

"oh Candidate X went to Pig's Knuckle General for residency"
"Never heard of it"
"me neither"

If you're familiar with the way law schools work, it's the argument that comes from going to a T-14 school vs any place else. Law being much more prestige driven, if you go to one of the top 14 schools, you can basically find a job anywhere. From there down, you have your regionally strong schools (as a hypothetical, if you want to end up in Dallas, going to Oklahoma is okay), then to your limited local schools (eg, if you want to stay in Omaha NE, going to Creighton is a smart move, but if you want to end up in Des Moines, Kansas City, Minneapolis, or Chicago, you'd be better going to better schools). Sure, there are some exceptions in every case, but in general, using Kansas City as an example, it's more much desirable to have gone to UMKC (local ties) KU or Mizzou (better schools) than to have graduated with a JD from Creighton.
 
How important to you guys feel it is to do away rotations to get a look at how the other programs work?
 
The one thing that ALWAYS gets overlooked in these types of conversations is location.

Where do you want to end up practicing?

Bottom line, there are only a few places that have a truly national name that's going to draw oohs and aahs. But the thing is most people dont' really need or want a national name to make their career what they want it to be. As the OP has already seen, there's often a strong case made for the locals. And even if you do eventually do decide to make some sort of major coastal shift, unless it's immediately after your residency or fellowship, then the issue is going to much more about what you've DONE than where you did it. Unless a place/group has had particularly poor run-ins with products of one specific program, it's likely to simply be a non-issue...

"oh Candidate X went to Pig's Knuckle General for residency"
"Never heard of it"
"me neither"

If you're familiar with the way law schools work, it's the argument that comes from going to a T-14 school vs any place else. Law being much more prestige driven, if you go to one of the top 14 schools, you can basically find a job anywhere. From there down, you have your regionally strong schools (as a hypothetical, if you want to end up in Dallas, going to Oklahoma is okay), then to your limited local schools (eg, if you want to stay in Omaha NE, going to Creighton is a smart move, but if you want to end up in Des Moines, Kansas City, Minneapolis, or Chicago, you'd be better going to better schools). Sure, there are some exceptions in every case, but in general, using Kansas City as an example, it's more much desirable to have gone to UMKC (local ties) KU or Mizzou (better schools) than to have graduated with a JD from Creighton.

Spot on post 👍
 
One of the top emergency medicine programs in the country is Hennepin in Minneapolis, Minnesota. Its a COUNTY hospital and I'm willing to bet that the EM residents end up better training than the progam ~100 miles away at the Mayo clinic :laugh:
 
so are residency programs ranked? is there some sort of "official ranking" which is widely used, kind of like US news? or is it just through hearsay?
 
The one thing that ALWAYS gets overlooked in these types of conversations is location.

Where do you want to end up practicing?

Bottom line, there are only a few places that have a truly national name that's going to draw oohs and aahs. But the thing is most people dont' really need or want a national name to make their career what they want it to be. As the OP has already seen, there's often a strong case made for the locals. And even if you do eventually do decide to make some sort of major coastal shift, unless it's immediately after your residency or fellowship, then the issue is going to much more about what you've DONE than where you did it. Unless a place/group has had particularly poor run-ins with products of one specific program, it's likely to simply be a non-issue...

"oh Candidate X went to Pig's Knuckle General for residency"
"Never heard of it"
"me neither"

If you're familiar with the way law schools work, it's the argument that comes from going to a T-14 school vs any place else. Law being much more prestige driven, if you go to one of the top 14 schools, you can basically find a job anywhere. From there down, you have your regionally strong schools (as a hypothetical, if you want to end up in Dallas, going to Oklahoma is okay), then to your limited local schools (eg, if you want to stay in Omaha NE, going to Creighton is a smart move, but if you want to end up in Des Moines, Kansas City, Minneapolis, or Chicago, you'd be better going to better schools). Sure, there are some exceptions in every case, but in general, using Kansas City as an example, it's more much desirable to have gone to UMKC (local ties) KU or Mizzou (better schools) than to have graduated with a JD from Creighton.

Thanks for the educational post. Again, I am just an M2.

This is what I was thinking it would be like. So two factors to consider I think are probably location and what you have done.

It is hard being 25, an M2 and having NO clue about what kind of physician I want to be. Lots of people that I knew as M2s who wanted to do primary care have completely changed their minds after doing rotations are want to do things like surgery, path, etc.

How do you handle this as an M2? Just take a deep breath, do well in classes, and kick ass on boards?

I did think it also matters on where you want to end up practicing. So when you are interviewed at residencies, (for example I am in the midwest and want to apply to the southeast) will they ask why I am applying so far away? (I want to go to the southeast as I like the climate, geography, etc.)

Also...it will matter what you have DONE...right? If you do a residency in tropical medicine/international medicine, there is a higher chance that you will get a job working in the specific area of expertise right? For example, health infrastructure management, pediatric AIDS control, etc.
This is where choosing a residency matters right?

Thanks again for all your input. I bow graciously at the amount of knowledge you all have and share.
 
The residency institutions were you will receive the best hands-on training and most autonomy are community-based.

The residency institutions were you will receive the greatest opportunity for fellowships and ass-kissing are academic.

That's the truth.

So, if you desire to be the best General Internist that you can possibly be, then stay away from academic institutions. If you desire to be best the Cardiologist that you can be, then you know what to do.
 
The residency institutions were you will receive the best hands-on training and most autonomy are community-based.

The residency institutions were you will receive the greatest opportunity for fellowships and ass-kissing are academic.

That's the truth.

So, if you desire to be the best General Internist that you can possibly be, then stay away from academic institutions. If you desire to be best the Cardiologist that you can be, then you know what to do.

wow seriously? is this really true?

and what motivates people to truly be specialists/do a fellowship post internal medicine training? usually the big bucks? easier life style sometimes?
 
wow seriously? is this really true?

and what motivates people to truly be specialists/do a fellowship post internal medicine training? usually the big bucks? easier life style sometimes?

I'd disagree. University programs absolutely do the best job of matching you into fellowships. However, I can't believe that community programs do that much better job of training their residents. I believe the depth and breadth of experience you can get a large academic tertiary care center is going to allow you to see some real zebras and hardcore stuff you may not run into at a community setting.

As for quality of training, there are pratfalls in both places. In academia, you absolutely do have the attendings who care more about publishing then spending time on education. However, in a community, you may have attendings more focused on revenue generation then education.

As for why people pursue internal medicine fellowships, the reasons are broad. Are there people who become Cards and GI because it's big money and they want to have a procedure? Absolutely. However, some people do it for love of a particular body system or patient population. Heck, even some fields like Geriatrics or Infectious disease don't even pay as much as someone could generate in a semi busi hospitalist role, but people do them because they love them.
 
I'd disagree.

Agree with your disagreeance. The "community" vs "academic" debate is as old as residency itself, it seems. The notion that academic programs fail to provide excellent clinical training is incorrect; as is the notion that community programs fail to provide opportunities for fellowship placement.
 
wow seriously? is this really true?

and what motivates people to truly be specialists/do a fellowship post internal medicine training? usually the big bucks? easier life style sometimes?

Special interest/research in a specific area of expertise is probably just as important as lifetyle or money. Not all the fellowships translate into more bucks (at least not that much more).
 
All a group or a hospital that hires you really cares about is your ability to safely generate revenue. Hospitals in particular, as employers, care very little about anything other than money. They would hire a homeless guy to do your job if they thought they could do it without any legal consequences but in practice they have to suck it up and get someone who is board certified.

They also care about your personality, that is, are you easy to work with our are you going to be a high maintenance employee who will cause them all kinds of scheduling and legal problems.

Where you went to medical school? The prestige of your residency program? Don't make me laugh. The only issue is whether you can fill the spot.
 
Oh, and I forgot to add that your hospital cares infinitely more about what a scummy drug-seeker says about you on a patient feedback form than it cares about what you think. In other words, the hospital wants you to be a subservient, ass-kissing robot who never, ever tells a patient anything except what they want to hear.

Not to mention that given the choice of having an excellent doctor who may not be very good at paperwork or a mediocre doctor who knows how to shovel the bureaucratic manure, the hospital will take the guy with the paperwork skills every time.

The bureaucratic overhead of American medicine is astonishing and growing at a much faster rate than it is in the rest of life where it is already growing an alarming rate.
 
Oh, and I forgot to add that your hospital cares infinitely more about what a scummy drug-seeker says about you on a patient feedback form than it cares about what you think. In other words, the hospital wants you to be a subservient, ass-kissing robot who never, ever tells a patient anything except what they want to hear.

Not to mention that given the choice of having an excellent doctor who may not be very good at paperwork or a mediocre doctor who knows how to shovel the bureaucratic manure, the hospital will take the guy with the paperwork skills every time.

The bureaucratic overhead of American medicine is astonishing and growing at a much faster rate than it is in the rest of life where it is already growing an alarming rate.

Thats sad
 
Thats sad


Well look...if you refuse to fuel the habit of a scummy drug seeker and, after sending him home with some motrin instead of the dilaudid (ultra-pure, legal heroin) that he craves, he writes a bad comment about you on the feedback forms the hospital inexplicably gives to the non-paying customers who would be considered shoplifters in any other business (I mean, if we embrace the "customer service" model of medicine like we're supposed to)...if you get a bad comment the hospital will investigate the complaint, document it, and may even use it to build a case to terminate your contract.

Bureaucrats simply do not care about you and, if the truth were known, many of them despise doctors and are always looking for a way to take you down a notch.
 
They also care about your personality, that is, are you easy to work with our are you going to be a high maintenance employee who will cause them all kinds of scheduling and legal problems.

Where you went to medical school? The prestige of your residency program? Don't make me laugh. The only issue is whether you can fill the spot.

Then why bust your balls and study hard to get into an ivy league residency? Shouldn't we all focus on becoming competent physicians who know how to get the job done (whether it be paper pushing or actual clinical medicine)?

So does it matter if one does an internal medicine residency at U of Arizona vs. say U of Pittsburgh? (minus where one wants to practice, etc.)

So much to think about...
 
Then why bust your balls and study hard to get into an ivy league residency? Shouldn't we all focus on becoming competent physicians who know how to get the job done (whether it be paper pushing or actual clinical medicine)?

So does it matter if one does an internal medicine residency at U of Arizona vs. say U of Pittsburgh? (minus where one wants to practice, etc.)

So much to think about...

First, "Ivy league" residency isn't a term that should be used. Some Ivy League schools do in fact, tend to have fantastic hospital systems (Harvard and Penn spring to mind) that can't be argued. However, not all the Ivy league schools default to that high standard like they do for undergraduate education.

Now, with that out of the way, to address what Panda said. I love the guy but you have to realize a lot of his (justified) complaints are somewhat amplified or unique to his field of emergency medicine. While all fields struggle with paperwork and bureacracy, the issue above about Press-Ganey scores and pill heads is somewhat unique to emergency medicine.

And I think the big issue here isn't necessarily comparing competitive residencies in one field versus another (although for things involving fellowships, that's a big deal) but the competitiveness of different fields versus eachother.

I hate to sound snobbish or classist, but a lot of the appeal of competitive fields in medicine is you don't have to deal with every Tom, Dick, and Jerk*ff who walk in through the door. Radiology is the obvious example by cutting out patients entirely, but (past residency) but being in a field like dermatology, where one is unique, allows you some power where you can decide what patients you're going to see and which you won't.

Here's an example. I had an absolutely obnoxious patient during my medicine rotation who I tried to set up an outpatient visit with an ENT office for a chronic complaint (trying to stay vague). Turned out this jerk had basically pissed off basically all the groups in town. They'd seen them, he'd not made his appointments, been rude to the doctors and staff. So, they'd "fired" him as a patient. This is something that can definitely be done in most fields of medicine, but if this guy shows up in the ER they're compelled to see him.

That's not to say that FM, Peds, IM, and Gen Surgeons can't "fire" patients, but it's seen much less often and more difficult to do.
 
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First, "Ivy league" residency isn't a term that should be used. Some Ivy League schools do in fact, tend to have fantastic hospital systems (Harvard and Penn spring to mind) that can't be argued. However, not all the Ivy league schools default to that high standard like they do for undergraduate education....

I would also add to this and suggest that you have to look at it on a specialty by specialty basis, because in some specialties, the best programs are ones you may not have heard of, or are affiliated with schools that are not at the top of the US News med school rankings, and in other specialties, a couple of the "ivy league" affiliated programs are known to be quite malignant and not places you would rank that highly if you were well advised. So Ivy league as a term to connote top notch is probably not very good terminology.

A top residency is useful for fellowships and academic medicine. It is also helpful for getting into certain practices which like to recruit from certain places. There are also career benefits from having worked with some of the top names in the field. And the residency name looks good when applying for research grants should you be involved in government or drug company research. And a lot of the big name places have better resources, often have their pick of the litter in terms of teaching faculty. And the "degree" you get from there looks impressive on your office wall. Will it be difficult to get from a no-name program to a job? Probably not so much in these days of physician shortages, so long as you aren't locked into a competitive geography. But you are assuming that you won't have different aspirations later on in life. Some people return from private practice to academia. Some people decide it would be fun to be part of a drug research trial. Some people decide mid residency that a fellowship in a subspecialty is where their interest really lies. So it pays to not shut doors on yourself so early.
 
First, "Ivy league" residency isn't a term that should be used. Some Ivy League schools do in fact, tend to have fantastic hospital systems (Harvard and Penn spring to mind) that can't be argued. However, not all the Ivy league schools default to that high standard like they do for undergraduate education.

Now, with that out of the way, to address what Panda said. I love the guy but you have to realize a lot of his (justified) complaints are somewhat amplified or unique to his field of emergency medicine. While all fields struggle with paperwork and bureacracy, the issue above about Press-Ganey scores and pill heads is somewhat unique to emergency medicine.

And I think the big issue here isn't necessarily comparing competitive residencies in one field versus another (although for things involving fellowships, that's a big deal) but the competitiveness of different fields versus eachother.

I hate to sound snobbish or classist, but a lot of the appeal of competitive fields in medicine is you don't have to deal with every Tom, Dick, and Jerk*ff who walk in through the door. Radiology is the obvious example by cutting out patients entirely, but (past residency) but being in a field like dermatology, where one is unique, allows you some power where you can decide what patients you're going to see and which you won't.

Here's an example. I had an absolutely obnoxious patient during my medicine rotation who I tried to set up an outpatient visit with an ENT office for a chronic complaint (trying to stay vague). Turned out this jerk had basically pissed off basically all the groups in town. They'd seen them, he'd not made his appointments, been rude to the doctors and staff. So, they'd "fired" him as a patient. This is something that can definitely be done in most fields of medicine, but if this guy shows up in the ER they're compelled to see him.

That's not to say that FM, Peds, IM, and Gen Surgeons can't "fire" patients, but it's seen much less often and more difficult to do.

Although to be fair, most of the time the ER docs get the easiest part of the obnoxious patient's care. They say **** it and admit the fake seizure or fake sickle cell crisis or back pain or belly pain or arm numbness or whatever the hell else, and they are probably doing the right thing. I mean they can't necessarily tell if a patient's faking it and it's easy as hell to just turf them up to the floor. The people who really get the crappy jobs dealing with these problem patients are whoever they get turfed to, whoever gets a stupid consult, and the hospital, who has to swallow the 3 day hospital stay, nursing care (high-maintenance), a CT, an MRI, a handful of labs, and all to settle on our diagnosis of exclusion - which was the ER guy's hunch to begin with - that there's nothing wrong with them.

I don't think we should get into the whole discussion about missing diagnoses and "faking" illness and all that, but I'm just saying, in private practice, yeah ER docs are stuck with every patient who walks in the door where most others can stay the hell away. But in training, academic medicine, and hospital employment, ER docs get the easy job of flipping a coin or whatever they do to decide whether to admit or send 'em packing, either way it's no longer their problem, unless they come in again, and even then chances are 50:50 it won't be on their shift.

To address the OP's question - residency is not like medical school, where basically you get the exact same education wherever you go, +/- a few research opportunities or better/worse rotation or two sprinkled in, and they're closely watched by the LCME to make sure. The ACGME is the accrediting body for residencies, and as was already stated, they don't go to lengths to ensure all residencies are equal, residencies are not all equal. Read up in the residency application forums, people are talking about whether they prefer a hospital with lots of trauma vs. very little trauma, with fellowships in-house (with resulting better ins to fellowship but perhaps less access to those cases pre-fellowship), different call schedules, dedicated research years, case volume, ....there's a concept of a "gentleman's program", etc. So the point is that there's a lot more that goes into the decision of where the "best" place to do residency is than where the "best place to do medical school is.

The best place to do medical school is the school with the best reputation unless you've got some compelling reason to go elsewhere. The best place to do residency is really really subjective and depends on your goals and preferences, and those come in a wide variety.

How do you handle this as an M2? Just take a deep breath, do well in classes, and kick ass on boards?

That's exactly how you handle it. Keep up the good work, a new set of challenges will be there waiting for you after you get through these (but they're more enjoyable and you'll feel like you're moving towards becoming a doctor, for better or worse) through M3 & M4.
 
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Although to be fair, most of the time the ER docs get the easiest part of the obnoxious patient's care. They say **** it and admit the fake seizure or fake sickle cell crisis or back pain or belly pain or arm numbness or whatever the hell else, and they are probably doing the right thing. I mean they can't necessarily tell if a patient's faking it and it's easy as hell to just turf them up to the floor. The people who really get the crappy jobs dealing with these problem patients are whoever they get turfed to, whoever gets a stupid consult, and the hospital, who has to swallow the 3 day hospital stay, nursing care (high-maintenance), a CT, an MRI, a handful of labs, and all to settle on our diagnosis of exclusion - which was the ER guy's hunch to begin with - that there's nothing wrong with them.

I don't think we should get into the whole discussion about missing diagnoses and "faking" illness and all that, but I'm just saying, in private practice, yeah ER docs are stuck with every patient who walks in the door where most others can stay the hell away. But in training, academic medicine, and hospital employment, ER docs get the easy job of flipping a coin or whatever they do to decide whether to admit or send 'em packing, either way it's no longer their problem, unless they come in again, and even then chances are 50:50 it won't be on their shift.

To address the OP's question - residency is not like medical school, where basically you get the exact same education wherever you go, +/- a few research opportunities or better/worse rotation or two sprinkled in, and they're closely watched by the LCME to make sure. The ACGME is the accrediting body for residencies, and as was already stated, they don't go to lengths to ensure all residencies are equal, residencies are not all equal. Read up in the residency application forums, people are talking about whether they prefer a hospital with lots of trauma vs. very little trauma, with fellowships in-house (with resulting better ins to fellowship but perhaps less access to those cases pre-fellowship), different call schedules, dedicated research years, case volume, ....there's a concept of a "gentleman's program", etc. So the point is that there's a lot more that goes into the decision of where the "best" place to do residency is than where the "best place to do medical school is.

The best place to do medical school is the school with the best reputation unless you've got some compelling reason to go elsewhere. The best place to do residency is really really subjective and depends on your goals and preferences, and those come in a wide variety.

Whoa Nelly. I agree with a lot of what you say, particularly about the poor sons-of-bitches in other specialties that get stuck with some of the winners that walk through our doors but it is not a "coin toss" or other random process that determines who we will admit simply because, with the exception of teaching services at academic hospitals, admitting physicians can and do refuse to admit patients who do not meet criteria for inpatient treatment. In other words, not every chest pain or seizure will be admitted because insurance companies or the government will not reimburse the admitting doctor for a "weak" admission.

I also want to point out that you are looking at Emergency Medicine from the safe end while I have to look at it from the pointy end. It is fairly routine for me to juggle ten or so patients simulateously of whom several may be really sick, oftentimes critically so. Contrary to poplular belief, we end up doing a great deal of the initial workup on most patients and many admitting physicians have come to expect a completely packaged patient and won't phone in admitting orders until they get it.

When the admitting phyiscian asks an Emergency Phyisician the results of the patient's "Double Stranded DNA" assay maybe it's time to admit already.

And then we can't admit everybody. Eventually most of our patients have to go home, ticking lawsuit timebombs waiting to destroy our careers if we missed something that will only seem obvious to a jury three years from now. Legally, Emergency Phyisicians are held to the same Standard of Care as a Family Physician who has an extensive relationship with a patient who he has known for twenty years; it being one thing to manage a nursing home patient who you have known for fifteen years and quite another to walk into a trauma bay to confront a stroked out, demented, completely uncommunicative Nursing Home Dump who has arrived with no records and out-of-date contact information for family living in Wyoming.
 
Then why bust your balls and study hard to get into an ivy league residency? Shouldn't we all focus on becoming competent physicians who know how to get the job done (whether it be paper pushing or actual clinical medicine)?

So does it matter if one does an internal medicine residency at U of Arizona vs. say U of Pittsburgh? (minus where one wants to practice, etc.)

So much to think about...

Unless you want to go into academic medicine at a prestigious medical center, there is no reason at all to bust your balls to get into any particular medical school or residency over another. All medical schools are good and prestige, with the exception of the above-stated caveat, should be the least important reason for selecting a residency.

Good residency programs are often prestigious but the converse is not true. I have personal experience with a residency program at a prestigious East Coast Medical Center that we will simply call "Earl" to avoid inciting the violent passions of its zealous defenders and it was incredibly weak.

There is, however, nothing inherently wrong with prestige. If you value the ability to say that you are a Harvard graduate then bust your balls. There is nothing wrong with this impulse at all which is a respectable part of your desire to strive for excellence. Just don't be upset if somebody from a no-name program who wants to work in a no-name city makes twice as much as you for half the work.
 
Thats sad

But true. Doesn't mean that you have to be a crappy doctor and become nothing but a paper-pusher however, only that being a good doctor and taking care of your patients is more complicated than just diagnosing their diseases. Remember, the bureaucrats hate patients and want to do as little for them as possible as they are the one unpredictable factor in the check-box world they are trying to construct.
 
Unless you want to go into academic medicine at a prestigious medical center, there is no reason at all to bust your balls to get into any particular medical school or residency over another. All medical schools are good and prestige, with the exception of the above-stated caveat, should be the least important reason for selecting a residency.

Good residency programs are often prestigious but the converse is not true. I have personal experience with a residency program at a prestigious East Coast Medical Center that we will simply call "Earl" to avoid inciting the violent passions of its zealous defenders and it was incredibly weak.

There is, however, nothing inherently wrong with prestige. If you value the ability to say that you are a Harvard graduate then bust your balls. There is nothing wrong with this impulse at all which is a respectable part of your desire to strive for excellence. Just don't be upset if somebody from a no-name program who wants to work in a no-name city makes twice as much as you for half the work.

That doesn't seem to agree with what others are saying: good residency = higher chance of good fellowship = higher chance of competitive specialty practice in a competitive location (San Francisco?). And then there is a notion that the medschool also has some role as to what residency spots you may get (e.g., the best neuro program seems to select a lot of students from Columbia). Ergo, prestige should matter in the end, but mainly in competitive specialties and likely competitive locations.
 
Ergo, prestige should matter in the end, but mainly in competitive specialties and likely competitive locations.

I am done competing if you will. I competed in high school for a good college and good scholarships, then in college for awards, then competed for a good med school (then it came down to choosing which one was the cheapest :laugh:), now I might be competing for residencies, then perhaps fellowships? then perhaps for jobs?

I want to be a competent physician first and foremost. As an M2 I am not attracted to ortho or derm. So I do agree that it has to do with future career goals.

If one wants to be a cardiologist----> academic center + research + in house fellowship
If one wants to be a hospitalist/internist ----> who cares where you do your residency as long as you can treat/handle patients with ease, efficiency, and confidence
If one wants to do international health/tropical health ---> you better go to a school with good connections/programs (vandy, minn. come to mind)

I am coming to understand what they were talking about when they said "it depends on what you want to do" and what one prioritizes.

If you want to become a dermatologist/ortho surg/rad onc dude in san francisco, then you are probably going to have to bust your balls! But to me, that is not worth it at all!!!
Any other thoughts?



Also, the post about changing careers midstream...how many docs do that? and this is probably a big shift, and hopefully other things in life won't be an issue...i.e. family, finances, etc.
Thanks for the posts, I learned a lot as always.
 
(relevant post from the internal medicine board)

I really think you know the response you are going to get here. Especially since you opened with, "Lots of people base their rank lists off prestige."

I'll give you my opinion though, as it may be a bit different.

I believe this is quite the double edged sword. If you pay absolutely no attention to prestige, especially if you would like to do one of the more competitive fellowships, then you may be limiting your options. Now, I think you have to ask yourself what your goals are as well as what your definition of success is. If you are eventually hoping to be on the administration side at a major university center, you may want to account more for prestige. I really believe that the main reasons for placing an emphasis on prestige are ambition and ego, as I have found absolutely no correlation between prestige and level of training.

Now, if you do the opposite and rank according to prestige, you may get into 'that' program. Now you've got a pedigree and probably some good contacts for fellowship and career options down the line. Again, ask yourself what your definition of success is and what kind of doctor you want to be. If the more prestigious program offers you the training and environment you are seeking and fits with your ideology, then you have your obvious choice. However, in my experience during this interview season, the bigger the name, the more they are living off of it; the bigger the city, the more they are living off of it. (ie, queston: how's the program?, answer: San Francisco's awesome!) Not always the case, but it sounds as though you are having the same experience. Be honest with yourself and be objective. If you want that prestigious program to be awesome bad enough it will seem as such.

So, you want to do Cardiology, you want to do research, and you want an academic career: any university program will get you there. Don't let anyone fool you into thinking that you have to go to Harvard to be a Cardiologist. You've got some great programs on your list, and if you do well and make some good contacts during residency, you will get a Cardiology fellowship. It may not be Cardiology at Stanford... but that may not matter to you. And if it does not matter to you: that's ok.

Define success to you and go after it. I would advise you that you will be more successful if you are happy while doing it. That being said, some people are happiest when they are miserable.

Sorry this is so long, I hope I have a bit of useful insight in there somewhere. Feel free to pm me.
 
(relevant post from the internal medicine board)
Good post. Here is another by radonc:


going to a top radonc program probably does help a little bit...it opens doors that may not be available if you go to a mediocre or even mid-tier program.

for example, certain private groups (mostly in desirable locations ie NYC, Boston, DC, Chicago) only hire people from top radonc programs...why? because they can. they are in a desirable location with a solid foundation and have the opportunity to attract top candidates. they market the fact that they have a harvard trained physician (or mskcc or mdacc).

going to a decent program def affects your choices if you are interested in academics. why you may ask? chances are that if you are at a pretty good program, you have more faculty, who may be more involved in the field...this lends itself to contacts at other programs. also, given that there really is no method of comparing people across the board (ie no public board score percentiles, grades, etc) the only way they can compare candidates is the interview, # of pubs, where they trained, and the strength/quality of the recommendation they receive.


It is safe to say that in many cases prestige doesn't matter (e.g., FM, IM, etc), but in some cases it matters significantly. Even if you think you are going to go into internal medicine, it doesn't hurt to be prepared in case you change your mind in medschool, which according to medstudents here happens a lot.
 
...
If one wants to be a hospitalist/internist ----> who cares where you do your residency as long as you can treat/handle patients with ease, efficiency, and confidence...


Also, the post about changing careers midstream...how many docs do that? and this is probably a big shift, and hopefully other things in life won't be an issue...i.e. family, finances, etc.
Thanks for the posts, I learned a lot as always.

First, a hospitalist at a big teaching university setting is often an academic medicine type position, and so residency credentials will absolutely matter.

Second, the number of physicians who change careers midstream isn't really so nominal that you can write it off. We all probably know folks in academia who did stints in private practice. This is not at all rare. I personally know many such people. Just look at the roster of faculty at any big academic setting and you'll find a fairly large percentage spent some time outside the ivy towers, learning their trade in private practice, only to return to the fold. And if you think about it, when you get older and your hand-eye coordination perhaps isnt what it once was, it's not so bad to have the option to do some teaching as a semi-retirement job.

You're kidding yourself if you are telling yourself you know exactly what you want to do with your life a decade or more down the road. Interests change, family situations change, finances cease to be as big an issue after years of working. So you just don't know, and for that very reason alone it might not be a bad idea to maximize your options.
 
[/INDENT]It is safe to say that in many cases prestige doesn't matter (e.g., FM, IM, etc),...

I would suggest that IM shouldn't be in this parenthetical. If you have aspirations in academic medicine, fellowships and certain subspecialties it actually probably does matter. That isn't to say you cant get there from other routes, just that it can help.
 
You're kidding yourself if you are telling yourself you know exactly what you want to do with your life a decade or more down the road. Interests change, family situations change, finances cease to be as big an issue after years of working. So you just don't know, and for that very reason alone it might not be a bad idea to maximize your options.

Law2Doc, first, thanks for all the good posts you make and thanks for the advice.

Second, given that you say that no one knows what they are going to do in a decade and options must be kept open.....that can be used either way:
-you could enjoy your life a little more, develop other interests (business/hobbies), develop a relationship, etc. instead of busting ones balls..i mean who knows what you will want in 10 years...perhaps you will look back and say, man i should have had more of a social life.
-you could look back and say, damn i wish i would have gotten an 87% on my anatomy final instead of an 80%. or when you are a rad onc physician in san fran...one could look back and say...damn i wish i had a nice quiet family practice in the midwest.

Also, I was going to bring up the point that...hypothetically you fail a year of med school but are dying to be a cardiologist/rad onc...I am sure you can make it happen, albeit with a lot more sacrifice than it would have initially cost.
I know this is n=1, but i know some FMGs who are starting their cardiology fellowship soon. And I also know a hand surgeon who failed a year of med school.

But you are probably right that keeping your options open is the best way to go about doing it but not necessarily killing yourself to keep those options open.

I may not know what I want in 10 years, but I want to say with all my heart that presitge (academic/professional) does not play into my equation. Working my balls off to become a dermatopathologist in San Fran will not be worth it to me even for $$$$$$$.
 
Law2Doc, first, thanks for all the good posts you make and thanks for the advice.

Second, given that you say that no one knows what they are going to do in a decade and options must be kept open.....that can be used either way:
-you could enjoy your life a little more, develop other interests (business/hobbies), develop a relationship, etc. instead of busting ones balls..i mean who knows what you will want in 10 years...perhaps you will look back and say, man i should have had more of a social life.
-you could look back and say, damn i wish i would have gotten an 87% on my anatomy final instead of an 80%. or when you are a rad onc physician in san fran...one could look back and say...damn i wish i had a nice quiet family practice in the midwest.
...

But you are probably right that keeping your options open is the best way to go about doing it but not necessarily killing yourself to keep those options open.

I may not know what I want in 10 years, but I want to say with all my heart that presitge (academic/professional) does not play into my equation. Working my balls off to become a dermatopathologist in San Fran will not be worth it to me even for $$$$$$$.

Well I'm not so sure it cuts both ways -- the former tends to be what you say when you are trying to justify not working particularly hard. It's rationalization. You have to ask yourself whether you are just making up excuses to justify slacking off. If you are premed (as your status indicates), I would suggest you will probably be killing yourself and hindering your social life in med school regardless -- it's often a lot harder to coast than you might think coming from college. You will be working harder than you ever have before, even if your aspirations are not a top residency. The difference between doing great or squeaking by may not be as great as you think, and so in most cases you are going to be doing your best regardless. And some med schools will fail you and make you retake courses if you don't put in some decent level of effort. The coasting and enjoying yourself you are likely trying to compare to your undergrad experience generally won't exist in med school. You are setting yourself up for failure (but literally and figuratively) if you are focusing on hobbies, social life and not busting balls as priorities. You need to plan to go full force in med school, and if you find you are doing solidly, only then should you consider paring things back. Because you will meet a lot of people who go full force and still end up flirting with the P/F line test after test. It's a learning process and the non-academic things should be fit in around what you need to do to get by, not be the priorities in your schedule. And it needs to be like this not just because med students are supposed to be a certain way, but in a few very short years you will be a resident, and your lack of knowledge can actually detriment patients. You are learning not just for your own career progression, but for their well being. You aren't in school to get the degree as much as to get the knowledge for which they award the degree. And you won't be as versed in medical knowledge if your goal is to not work very hard. There will be people who do their best and never get that good, but if you aren't willing to put in the effort, then maybe this isn't an appropriate path.
 
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Well I'm not so sure it cuts both ways -- the former tends to be what you say when you are trying to justify not working particularly hard. It's rationalization. You have to ask yourself whether you are just making up excuses to justify slacking off. If you are premed (as your status indicates), I would suggest you will probably be killing yourself and hindering your social life in med school regardless -- it's often a lot harder to coast than you might think coming from college. You will be working harder than you ever have before, even if your aspirations are not a top residency. The difference between doing great or squeaking by may not be as great as you think, and so in most cases you are going to be doing your best regardless. And some med schools will fail you and make you retake courses if you don't put in some decent level of effort. The coasting and enjoying yourself you are likely trying to compare to your undergrad experience generally won't exist in med school. You are setting yourself up for failure (but literally and figuratively) if you are focusing on hobbies, social life and not busting balls as priorities. You need to plan to go full force in med school, and if you find you are doing solidly, only then should you consider paring things back. Because you will meet a lot of people who go full force and still end up flirting with the P/F line test after test. It's a learning process and the non-academic things should be fit in around what you need to do to get by, not be the priorities in your schedule. And it needs to be like this not just because med students are supposed to be a certain way, but in a few very short years you will be a resident, and your lack of knowledge can actually detriment patients. You are learning not just for your own career progression, but for their well being. You aren't in school to get the degree as much as to get the knowledge for which they award the degree. And you won't be as versed in medical knowledge if your goal is to not work very hard. There will be people who do their best and never get that good, but if you aren't willing to put in the effort, then maybe this isn't an appropriate path.

I guess I haven't updated my profile, but I am an M2....
I can honestly say I don't bust my balls...that is I go to class and study a fair amount (I could study more if i sacrificed friends, music, other hobbies, sanity, etc.)......and I am in the top third of my class...
 
I guess I haven't updated my profile, but I am an M2....
I can honestly say I don't bust my balls...that is I go to class and study a fair amount (I could study more if i sacrificed friends, music, other hobbies, sanity, etc.)......and I am in the top third of my class...

If you are in the top third of your class you will be able to get a good residency and I guess I don't understand why you wouldn't look at good residencies.
 
That doesn't seem to agree with what others are saying: good residency = higher chance of good fellowship = higher chance of competitive specialty practice in a competitive location (San Francisco?). And then there is a notion that the medschool also has some role as to what residency spots you may get (e.g., the best neuro program seems to select a lot of students from Columbia). Ergo, prestige should matter in the end, but mainly in competitive specialties and likely competitive locations.

San Francisco may be a competitive location but the desire of many physicians to live there drives down the salaries that employers are willing to pay. It's the simple economics of supply and demand of which medicine is not immune. I know, for example, a resident who worked and networked his keester off to get a position in San Diego that pays just barely half as much as I will be making for a similar job with similar hours in a fairly nice but "non-competitive" city.

Additionally, my hospital which is about as unprestigious and non-descript as you can get nevertheless has the full gamut of fellowships from which are produced cardiologists and nephrologists the equal in earning power as any coming out of the Dukes and the Harvards of the world. I repeat, the number one criterion for employment as a physician is your ability to safely generate revenue. This is also the number two, three, four, and five criterion.
 
I would suggest that IM shouldn't be in this parenthetical. If you have aspirations in academic medicine, fellowships and certain subspecialties it actually probably does matter. That isn't to say you cant get there from other routes, just that it can help.

I didn't know IM is considered to be competitive.

It's good that you agree about the importance of the prestige in some cases. Too many people deny that in this forum, including the experienced ones. Whenever I see a thread where someone is trying to decide between a better school or a cheaper school, I try to raise the issue that it is very path dependent. Though perhaps one could argue that anyone vacillating about the choice probably doesn't need the prestige. Quantifying the prestige is even tougher. It may be somewhat easier to pay about 50K extra for it, but it isn't such an easy decision after the difference surpasses 100K.
 
San Francisco may be a competitive location but the desire of many physicians to live there drives down the salaries that employers are willing to pay. It's the simple economics of supply and demand of which medicine is not immune. I know, for example, a resident who worked and networked his keester off to get a position in San Diego that pays just barely half as much as I will be making for a similar job with similar hours in a fairly nice but "non-competitive" city.

Additionally, my hospital which is about as unprestigious and non-descript as you can get nevertheless has the full gamut of fellowships from which are produced cardiologists and nephrologists the equal in earning power as any coming out of the Dukes and the Harvards of the world. I repeat, the number one criterion for employment as a physician is your ability to safely generate revenue. This is also the number two, three, four, and five criterion.

It is now almost common knowledge that underserved areas pay higher salaries to doctors; however, I think that sometimes this effect is overestimated. I have looked at some salary charts, and like everything else in life, the magnitude of salary variation is very specialty dependent. For example, it seems that for internal medicine NY has the lowest salary (as much as 50K lower than other regions in the US). At the same time, there are some surgical subspecialties (I think NS was one) where the highest salaries are actually in the west. The supply of each specialty can vary greatly within any one state and that's probably why some are not affected by geographical density.

It is also not just about the salary. Some of us would be willing to get 10-30K a year less to live in the coasts rather than in the south or Midwest. If you are happy with your set up, you'll probably be more adventuresome and run a better business despite a somewhat lower salary. There is also a higher concentration of wealth in the coasts and the opportunity to make more money is higher (plastic surgery comes to mind).

Maybe it doesn't matter much where you do your residency if you are trying to do a fellowship just at any place in the country that will accept you. Nevertheless, I would say that someone with a pedigree might have an easier time getting leadership positions (politics is littered with Ivies) and even starting a business or doing a research for a drug company. Pedigree can affect your income in that way. As for "safe" doctors, I think that hospitals just want to make sure that you are not going to involve them in a patient-doctor lawsuit. Though it should be ok to be unconventional in terms of your views about the healthcare system and what needs to be done. It is possible that your opinions will be more accepted if you have the right pedigree. It's just human bias. Could also come in handy when you are trying to advance your rank within your own hospital or trying to create a partnership for a private practice.
 
If you are in the top third of your class you will be able to get a good residency and I guess I don't understand why you wouldn't look at good residencies.


Isn't a "good residency" relative?

And I want to leave the snow for the sun baby!! Just a few more years!
 
Isn't a "good residency" relative?

As is everything, I suppose.

As others have said before, it all depends on what you want to do with your life and where you want to live. If you want to go into private practice with a mostly in-clinic practice, I don't think it will really matter where you train, and location should be your primary concern, as Panda Bear is correct in saying most of it will be how easy it is to work with you (private group) and how much money you can make: how many times you'll be sued (hospital). If you want to go into an academic practice, the name will probably carry more weight if for no other reason than people in the academic world are obsessed with pedigree and where you trained/who trained you/etc. It will also give you a greater exposure to research during your residency.

The debate, then, is whether or not a community program can train you as well as an Ivory Tower, and here is where things become relative. If you are at a small community program in internal medicine, you will be transferring some of your sicker patients to the tertiary care center because your hospital won't be equipped to care for them. The residents at the tertiary care center will then gain that experience that you've lost. Does it really matter if you want to run your own outpatient clinic and peripherally follow (if at all) your patients should they be hospitalized? No, you just need to recognize when someone is sick and needs to be in a hospital. Can you still become an interventional cardiologist from a small community program? Sure, but your path will most likely be more difficult and it will require a little more work on your part to get there.
 
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I didn't know IM is considered to be competitive.

It's good that you agree about the importance of the prestige in some cases. Too many people deny that in this forum, including the experienced ones. Whenever I see a thread where someone is trying to decide between a better school or a cheaper school, I try to raise the issue that it is very path dependent. Though perhaps one could argue that anyone vacillating about the choice probably doesn't need the prestige. Quantifying the prestige is even tougher. It may be somewhat easier to pay about 50K extra for it, but it isn't such an easy decision after the difference surpasses 100K.

Around forty to fifty percent of those going into internal medicine are going to go on to do a fellowship (and who knows how many want to do it so they can't compete). Considering how competitive the big two are (Cards and GI) unless you are absolutely sure you want to do community hospitalist or be primary care I'd recommend going to the best program you can.
 
As I said before, some IMGs that I know are doing cardiology fellowships soon. They did a year or two of research, but I guess that is a sacrifice that they are willing to make.

I think any fellowship is possible...regardless of what residency one does. But if one goes to Pigskin Hospital Residency in BME, he/she might have to do some research at the institution they want to do a fellowship in...kiss some butt...and be a good clinician/scientist.

These (above) are another reason to why cardio/GI are made even more competitive. How does a PD choose between a stellar AMG who has "paid his dues" (good grades, steps, good internal medicine board/shelf scores) vs. an IMG who is just as competent (maybe not as good a scores/school) but does research for him and produces some really good papers?
 
It is now almost common knowledge that underserved areas pay higher salaries to doctors; however, I think that sometimes this effect is overestimated. I have looked at some salary charts, and like everything else in life, the magnitude of salary variation is very specialty dependent. For example, it seems that for internal medicine NY has the lowest salary (as much as 50K lower than other regions in the US). At the same time, there are some surgical subspecialties (I think NS was one) where the highest salaries are actually in the west. The supply of each specialty can vary greatly within any one state and that's probably why some are not affected by geographical density.

It is also not just about the salary. Some of us would be willing to get 10-30K a year less to live in the coasts rather than in the south or Midwest. If you are happy with your set up, you'll probably be more adventuresome and run a better business despite a somewhat lower salary. There is also a higher concentration of wealth in the coasts and the opportunity to make more money is higher (plastic surgery comes to mind).

Maybe it doesn't matter much where you do your residency if you are trying to do a fellowship just at any place in the country that will accept you. Nevertheless, I would say that someone with a pedigree might have an easier time getting leadership positions (politics is littered with Ivies) and even starting a business or doing a research for a drug company. Pedigree can affect your income in that way. As for "safe" doctors, I think that hospitals just want to make sure that you are not going to involve them in a patient-doctor lawsuit. Though it should be ok to be unconventional in terms of your views about the healthcare system and what needs to be done. It is possible that your opinions will be more accepted if you have the right pedigree. It's just human bias. Could also come in handy when you are trying to advance your rank within your own hospital or trying to create a partnership for a private practice.

The differences in pay can be much larger than this - look for data on pay for freshly minted radiologists in, say, Louisiana versus, say, NYC - I have seen staggering differences.

Add to that the fact that in the places where the pay is much higher to start with, the cost of living is much lower and the pay differential gets multiplied.
 
I wonder what the future holds for this trend. Will physicians set up shop in rural areas, make bank, then up and leave and move back to Boston or New York? Interesting.

Anyway, to be OT, I would say that there are so many factors that go into it. If I wanted to try to match in FM or IM, I'd shoot for top programs since I think in the long run, it's better education and better jobs. In something like Derm, I'd be ecstatic to get in anywhere.

Also consider that for your designated specialty of choice, it really comes down to finding about individual programs and figuring out if they are a proper fit for you. It's more about a 3 to 5 year job and how happy you'll be there vs. all the glitz. But again, the glitz can factor in as well. For a field I'm considering, I've been warned from multiple sources about staying away from an Ivy League school that I would otherwise think would be pretty excellent for everything...just as an example.
 
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