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You could also do a mid-tier IM residency and work at a mid-tier program. I worked at both a mid-tier and a top-tier teaching hospital prior to medical school, and there was no difference between the types of cases that the residents at each hospital saw. Both hospitals had a full roster of fellowships in-house, a similar number of beds, and similar procedure loads. I can't see how going to one versus the other would actually make you a better physician.
Many of the non-academic physicians at the top-tier were IMGs and DOs with community or mid-tier residencies under their belts, treating the exact same patients that the guys that were Hopkins and Harvard educated and trained were, but with the added bonus of not having to teach a bunch of residents and medical students or put in long hours working in the lab after hours. Personally, I don't necessarily want to work in the middle of nowhere forever- I might want to work at a mid-ranked teaching hospital someday (and will likely pursue a mid-tier residency if my board scores pan out), albeit on the non-academic service, because research and teaching are completely uninteresting to me. There's 5,686 hospitals in the US, hundreds of which have enough beds to see interesting cases, most of which are outside of the elite umbrella. That's plenty of opportunities to find a nice place to fit my needs.
As to the podunk IM guy versus the JHU guy, there's actually a lot more to it than that. Throw that guy from JHU into working at a community hospital with very few specialists and very little support staff and he'll flounder- specialists take a lot of the interesting things at places like JHU that an IM resident learns to be capable of in a smaller residency. When you're the only residents in the hospital, you're intubating, placing lines, running codes, overseeing crazy numbers of patients, etc. At the top program, every code would have literally 30-50 residents and medical students show up, a gaggle of white coats that will, for the most part, be doing nothing but watching. At a small program where the whole hospital has 3 or 4 residents on at a time, there's a good chance you'll be running a whole lot of codes by the time you get out. You'll probably do a whole lot more of the common ICU procedures due to lack of competition for patients. You'll be better at the day-to-day practice of actually being a functional physician in a low-resource environment where you don't have backup or every specialty on call. The downside is, you lose exposure to a lot of the zebras and difficult cases, so you'd flounder pretty hard in a big academic environment. The training is very different, in both cases.
I guess the only reason I'm rambling on about this whole topic is that it is less your goals that concern me, and more how you view the vast majority of other physicians as "lesser." It's not a good attitude to have, as arrogance and elitism aren't really all that becoming of traits for a physician to possess. And that's just how you look at your colleagues- I can't even imagine how pathetic the general public must look to you.
