Why is It so Important to Do Residency at a "Good" Place?

[Coastie]

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You're entitled to your opinion, but the fact remains if you want better jobs, better cases, better reputation, and better training as a physician, go to an academic center.

For each specialty, the #1 training program is always found at an academic center.

Don't want to go to the #1? That's fine. You'll probably still be OK for your career goals.

Not going to an academic center will limit your private practice and academic options. If you're OK with limiting your career opportunities, choose the community program.

#1 is simply wrong, in my experience, and #2 is highly debatable.

There has been plenty of discussion about case volume in the surgery forums, so I'll just link to that - http://forums.studentdoctor.net/showthread.php?t=816390

But at the programs I interviewed at, the community programs had higher operative case volume than the academic programs, sometimes by a huge margin, and my exposure as a resident further validates that. There is no published aggregate data of this though.


If you want to be in academics. If your plan is to do gall bladders, colectomies, and Nissens in the community, then being third scrubbed into a robotic Whipple or doing a pelvic exenteration is not the best use of your time. It would be much more useful to be doing the things you plan to be doing, and to do them repeatedly. Nor would it be useful to take several years out your training to do research.

 

[mlw03]

quite the pissing contest we have going on here.

 

[Blitz2006]

quite the pissing contest we have going on here.

Yeah this thread is great,

I have to admit, its becoming transparent that "prestige/namebrand" is not really beneficial in the "real world".

Amazing how us medical students get brainwashed otherwise....

Thats why I love SDN, opens our eyes to reality.

 

[Coastie]

Yeah this thread is great,

I have to admit, its becoming transparent that "prestige/namebrand" is not really beneficial in the "real world".

Amazing how us medical students get brainwashed otherwise....

Thats why I love SDN, opens our eyes to reality.

Don't kid yourself.

It matters in the real world.

 

[mlw03]

Don't kid yourself.

It matters in the real world.

That's right... because Coastie says so.

Not saying you're right or wrong, but let folks make their own choices without because quite so condescending is all. Your "fact" is another man's opinion.

 

[Coastie]

That's right... because Coastie says so.

Not saying you're right or wrong, but let folks make their own choices without because quite so condescending is all. Your "fact" is another man's opinion.

OP asked for our opinion. I don't hedge like some folks. Op can take it or leave it,but the SDN ethos of "all medical education is created equal" is ridiculous and touchy feely.

 

[45408]

OP asked for our opinion. I don't hedge like some folks. Op can take it or leave it,but the SDN ethos of "all medical education is created equal" is ridiculous and touchy feely.

If SDN had an ethos, that certainly wouldn't be it. I'm certainly not saying it.

 

[DocDanny]

Don't kid yourself.

It matters in the real world.

Again, it depends. How would going to an academic center, and having fellows do all my procedures, and seeing zebras every day, and having to do research, how would any of that make me a better Hospitalist?

You are still making a circular argument. Academic centers are better because they are more prestigious, and they are more prestigious because they are better.

Can you explain to me how I'd be better prepared to be a Hospitalist if I went to an Academic Program? Without simply saying "because it is better".

 

[Coastie]

Again, it depends. How would going to an academic center, and having fellows do all my procedures, and seeing zebras every day, and having to do research, how would any of that make me a better Hospitalist?

You are still making a circular argument. Academic centers are better because they are more prestigious, and they are more prestigious because they are better.

Can you explain to me how I'd be better prepared to be a Hospitalist if I went to an Academic Program? Without simply saying "because it is better".

Who said its only fellows and zebras at academic centers?

Sorry man. Seems like no matter what I say you won't listen. Good luck in your career.

 

[DocDanny]

Dude, what makes you think I'm at an academic program?

What's wrong with saying some places are better than others?

Some places ARE better than others. But being a community or academic hospital has NOTHING to do with it.

If you aren't at an academic hospital, why all this hostility towards community centers?

 

[Coastie]

Some places ARE better than others. But being a community or academic hospital has NOTHING to do with it.

If you aren't at an academic hospital, why all this hostility towards community centers?

No hostility to community centers. They just aren't the best place to receive medical training.

 

[DocDanny]

Who said its only fellows and zebras at academic centers?

Sorry man. Seems like no matter what I say you won't listen. Good luck in your career.

At my community hospital, we don't have to compete with any fellows for procedures, and while we see zebras, the majority are bread and butter cases. This will make me a better Hospitalist. What exactly does an academic center have to offer me? You don't seem to have an answer.

I don't need luck in my career. I'm exactly where I want to be, getting the training I need.

 

[mlw03]

OP asked for our opinion. I don't hedge like some folks. Op can take it or leave it,but the SDN ethos of "all medical education is created equal" is ridiculous and touchy feely.

Folks aren't hedging, but you're failing to recognize the possibility that some community programs are better than some academic programs. Overall, sure, I would agree that academic programs are a safer bet for solid training (at least in my specialty), but your 100% all of the time mantra is where you come across sounding rude and holier-than-thou. I don't think anyone is claiming all medical education is created equal.

You make some solid points. Just come down a little bit from your high horse and you'll make a much more persuasive argument. Plus, you won't sound quite so much like a jack-a*#.

 

[DocDanny]

No hostility to community centers. They just aren't the best place to receive medical training.

Based on what reasons?

Fame does not equal good training.

And no hostility to community centers? You've been nothing but hostile to community centers, and have looked down on people who go there as unmotivated, lazy slackers.

 

[Coastie]

Folks aren't hedging, but you're failing to recognize the possibility that some community programs are better than some academic programs. Overall, sure, I would agree that academic programs are a safer bet for solid training (at least in my specialty), but your 100% all of the time mantra is where you come across sounding rude and holier-than-thou. I don't think anyone is claiming all medical education is created equal.

You make some solid points. Just come down a little bit from your high horse and you'll make a much more persuasive argument. Plus, you won't sound quite so much like a jack-a*#.

Name one specialty where a community hospital is the top of the heap in terms of residency training.

Of course there are some community centers which are better than academic. I never said otherwise.

 

[Coastie]

Based on what reasons?

Fame does not equal good training.

And no hostility to community centers? You've been nothing but hostile to community centers, and have looked down on people who go there as unmotivated, lazy slackers.

No hostility, they just aren't the best. Not everyone is equal nor does everyone get to be "the best".

There are some great community centers. If you want the best training and career opps, however, you will have to go to a major academic center.

 

[Coastie]

At my community hospital, we don't have to compete with any fellows for procedures, and while we see zebras, the majority are bread and butter cases. This will make me a better Hospitalist. What exactly does an academic center have to offer me? You don't seem to have an answer.

I don't need luck in my career. I'm exactly where I want to be, getting the training I need.

Everyone needs some luck once in a while. So, good luck.

 

[DocDanny]

Well, I don't believe in the concept of "best", so that's a loaded question. But...

Akron City has an excellent reputation state wide, and their residents have plenty of opportunities for fellowships. They've always been ahead of the curve on residency hours, which has prevented burnout. The residents there were also very very happy, and knowledgeable.

My hospital is a little smaller. Most of us want to do general medicine. But the ones who want to do fellowships do well. One friend got a fellowship in ID, two in heme/onc, and another got into Pulmonary/CC.

 

[DocDanny]

Good luck to you too, buddy. No ill will.

I just want you to explain how I'd get the best training for being a Hospitalist at an Academic Hospital.

 

[mlw03]

Name one specialty where a community hospital is the top of the heap in terms of residency training.

Of course there are some community centers which are better than academic. I never said otherwise.

I can't comment intelligently about specialties other than my own, in which academic programs are far stronger than community programs in general.

The OP asked some of the pros and cons of academic versus community programs. I think that's been answered. Not much more to say really. S/he will have to decide what's best for them, in their specialty, and with their particular career goals. I simply disagree with your assertion that academic=best 100% of the time.

 

[Coastie]

Well, I don't believe in the concept of "best", so that's a loaded question. But...

Akron City has an excellent reputation state wide, and their residents have plenty of opportunities for fellowships. They've always been ahead of the curve on residency hours, which has prevented burnout. The residents there were also very very happy, and knowledgeable.

My hospital is a little smaller. Most of us want to do general medicine. But the ones who want to do fellowships do well. One friend got a fellowship in ID, two in heme/onc, and another got into Pulmonary/CC.

If you don't believe in "best", then that tells any reader of this thread all they need to know.

Tells me too.

What's medicine coming to these days?

 

[Law2Doc]

The exposure to medicine and training at a community hospital is not the same as a large academic center.

Pros and Cons to each, but the Pros of going to a large, renown center outweigh the Pros of a community center.

1) Greater volume of cases
2) Better cases
3) Better job prospects
4) Better fellowship prospects


The "everybody wins a trophy" mentality of medicine isn't reflective of the real world. It matters where you train, so train at the best place you can. In every specialty, the best place is an academic center.

Actually, in my experience #1 is simply false. The big name places have many residents and fellows, so the per person volume is considerably less. The next two points are extremely debatable, and depend a lot on your goals. Certainly if you plan to stay regional, a well regarded local community place will be adequate for local private practice jobs, and the value of zebras over bread and butter is only meaningful if you stay at academic centers. I tend to agree with your fourth point.

 

[Law2Doc]

No hostility to community centers. They just aren't the best place to receive medical training.

We are debating this very issue and you seem to be the only one not appreciating that both types of programs have their virtues and detriments, and neither really wins hands down as better "training". Many community places give you far more hands on training, starting earlier in your residency, with a much better bread and butter to zebra ratio than the big name academic places. Some big name places have residents in the shadows of fellows, with attendings far more interested in their research than clinical teaching obligations. But you do get more CV value. It would be hard with a straight face to say one type of training is the "best", although each might prepare you for a very different role in medicine. So yeah, if you are shooting for academics, the academic place will serve you better. But you are kidding yourself if you thing that same analysis serves you well in other arenas.

 

[DocDanny]

If you don't believe in "best", then that tells any reader of this thread all they need to know.

Tells me too.

What's medicine coming to these days?

Ha ha! That tells you all you need to know about me? Why, because I don't see residencies as a set of ranked numbers?

Frankly, I think your obsession with prestige says a lot about you. If you aren't in an academic program, then why do you feel the way you do? Are you unhappy in your residency, and thinking the grass is greener on the other side?

I think that different residencies are better for different people. Nothing more, nothing less. So many residencies are great. All kinds, and you can get excellent training all over the country.

 

[Coastie]

We are debating this very issue and you seem to be the only one not appreciating that both types of programs have their virtues and detriments, and neither really wins hands down as better "training". Many community places give you far more hands on training, starting earlier in your residency, with a much better bread and butter to zebra ratio than the big name academic places. Some big name places have residents in the shadows of fellows, with attendings far more interested in their research than clinical teaching obligations. But you do get more CV value. It would be hard with a straight face to say one type of training is the "best", although each might prepare you for a very different role in medicine. So yeah, if you are shooting for academics, the academic place will serve you better. But you are kidding yourself if you thing that same analysis serves you well in other arenas.

I said both have pros and cons. It doesn't follow that "neither wins in training".

The SDN hedge of "everyone is equal in training" wins again, it appears.

Training in medicine matters. Carib schools don't teach as well as American med schools. PCOM-GA doesn't prepare you as well for residency as Emory. Community programs are viewed as subpar compared to academic centers.

Why is this fact the third rail of sdn?

 

[45408]

Name one specialty where a community hospital is the top of the heap in terms of residency training.

Of course there are some community centers which are better than academic. I never said otherwise.

It depends on what you want to do within your specialty, but you keep ignoring that fact repeatedly. Community programs average higher operative volume than academic programs in general surgery, so if you want to operate and not do research, then the best program for you might be a community one.

 

[DocDanny]

The only one who really seems to see community hospitals as inferior is you. And really? Now you are insulting the forum as well?

Several people have pointed out that community hospitals have higher patient loads, and more bread and butter cases, and are therefore can be better for someone who wants to do general medicine, general surgery, Peds, pretty much everything primary care.

Meanwhile, the only argument you seem to be able to make is 'community hospitals suck because everyone says so'.

 

[DocDanny]

I'm going to ask again in case you missed it up above:

Why would an academic center do a better job of training me to be a Hospitalist?

 

[Winged Scapula]

Real world example:

when working (after fellowship) at an academic medical center, I knew where many of my colleagues trained and prestige of that institution was considered during job interviews (but was not a major factor in hiring)

now working in a community PP, I have no idea where the vast majority of my colleagues trained; its just not the most important factor when it comes to referrals and job interviews. We don't sit around the physician's lounge and talk about it

the reputed surgical skill of my colleagues favors community trained surgeons (which I posit is probably related to volume especially with B & B cases)

and finally (to see if we can transition to another oft argued piece of SDN lore): in my community, there is still some bias against DOs - from patients and "old timey" physicians

 

[dragonfly99]

I think for internal medicine sometimes there is benefit to going to a larger hospital that gets more referrals of complex/weird cases (which is usually a large university hospital). I'm a fellow at a university hospital and I don't "take" procedures from interns and residents. Trust me, at this point in my career putting in a central line is just not very exciting and neither is a paracentesis. So I do think it is kind of a myth to say that fellows "take" procedures from interns and residents at university hospitals, although I guess it does happen on occasion. I think for someone who is going to do outpatient primary care (or mostly outpatient medicine) one could make a definite argument for training at a good community hospital. For one thing, sometimes the nicer community hospitals have better run "resident clinics" (this is the weekly continuity clinic for internal medicine residents where we see the same patients repeatedly. You would be surprised how little emphasis on outpatient medicine there is, and/or how crappy the organization can be, in some resident clinics at "famous" IM programs. At places where almost 100% of residents go on to do fellowship, sometimes the program just doesn't care about teaching outpatient medicine and/or thinks that it's not "hard" so that any resident who can take care of sick ICU or floor patients can just figure out outpatient medicine on his own. There may be SOME truth to that but there's also a finesse to managing outpatients and certainly a lot of actual internal medicine practice (or even cardiology) is outpatient.

Most community hospitals, I would argue, won't train you as well to take care of sick medical ICU patients or CCU patients, because a lot of those hospitals don't have a lot of those type patients...some of them in fact transfer out a lot of those patients to some other hospital. Some, but not all...there are many different types of "community" hospitals and many different types of "university" hospitals. There are community hospitals that have big fat ICU's and are some of the "go to" hospitals in their areas for critically ill patients. There are some big name internal medicine programs that are a little notorious for being a bit too cush in terms of having mostly rich, entitled patients and having attendings and fellows who micromanage cases or patients who only want to deal with mainly the fellow or attending. At some of these places residents don't get to do many procedures, which would be bad if you wanted to be a hospitalist who does critical care stuff, a cardiologist or do pulmonary/critical care fellowship. A lot of hospitalists now just do mainly floor patients, and have a separate guy/gal to take care of the ICU players, or at least have critical care consultants managing the vent and the procedures, though.

I have definitely seen and heard a lot of people say that some of the "academic" surgeons are not as good at operating. It makes sense because to get good at doing procedures the best way is to do a lot (with someone who knows what he/she is doing, of course). I think this problem also sometimes happens with interventional cardiologists too. You may not want some guy who spent a whole year of his interventional fellowship studying stem cells to put in your stents, because the guy who spent all 2 years cathing people and deploying stents might be better at it. Also the cath lab "numbers"/patients worked on are not good at some of the "famous/academic" cards programs. It's not uniformly true but it is sometimes the case.

 

[Law2Doc]

I said both have pros and cons. It doesn't follow that "neither wins in training".

The SDN hedge of "everyone is equal in training" wins again, it appears.

Training in medicine matters. Carib schools don't teach as well as American med schools. PCOM-GA doesn't prepare you as well for residency as Emory. Community programs are viewed as subpar compared to academic centers.

Why is this fact the third rail of sdn?

I didn't say everyone was equal. I said you have to find the happy medium between the big academic center and the community shop to minimize the negatives and maximize the positives, which might actually be a moderate sized academic program with enough zebras and hands on workload, but not overrun by fellows or "research first" attendings. BTW many many of the better community programs are exclusively filled with US allo grads, so your suggestion that we are talking about Caribbean or DO places is simply inaccurate, and suggests to me that you really lack enough info to be taking the stand you are taking. There are plenty of Emory grads training at community places in multiple specialties.

So again it's naive and inaccurate to say community places are "viewed as subpar." By whom? Maybe by you, but not by the local practitioners who hire folks from the better community places year after year. As Dragonfly suggested if you don't get enough hands on work your training was subpar, regardless of the name on your residency certificate. Thats true in surgery, interventional cardiology, whatever. This rarely happens at the smaller, short staffed hospitals. It might if you are one of many residents working under many fellows at an academic center. Not true everywhere, but certainly there are some very big brand name places that meet this definition. Again, this doesn't mean your resume won't look great for fellowship. But it might mean your training was not as good as your counterparts.

 

[Sarcoidosis]

Can you explain to me how I'd be better prepared to be a Hospitalist if I went to an Academic Program? Without simply saying "because it is better".

Again, it seems that people in the thread need to look at the BIG PICTURE.

Factors such as case load, fellows taking procedures, location, zebras, malignancy, and other things that people have mentioned here are important at the individual level, but not at the grand scheme of things.

However a good program, and "Top Program", and Academic Center.... on AVERAGE if not all the time have a way of thinking....
This academic program may have tons of fellows stealing procedures, they may have all zebras, they may be malignant, they may not have any niceties that a person would want, however they may still be a "Top Academic Program" they may be the Best because they teach you a "way of thinking", they not only "teach you" but teach you the process of teaching yourself.....

So as in your question above, you may see a lot of patients in a Community Hospital and that would prepare you to be a Hospitalist, however, you may miss out on the leading edge research and trials that may be happening and why they are happening and what the new changes in years to come may be and how something that is so ingrained in your management may be completely obsolete a few years from now. So don't despair that you have not see a large patient load from a community center and that you will not be as good a hospitalist... you will have plenty of opportunities to do this after you graduate...

No one finishes a program ready to do it all...

 

[inspirationmd]

Name one specialty where a community hospital is the top of the heap in terms of residency training.

Of course there are some community centers which are better than academic. I never said otherwise.

I would venture to say that in Family Medicine the some of the best programs are unopposed community programs where they are responsible for managing the ICU and doing the bulk of the floor work as compared to a university program where the IM residents would likely take the bulk of the IP duties. Even though OP skills are their bread and butter there is a strong emphasis on IP duties as well. Also I have friends learning intubation skills from the Anesthesia/Pulm CC attendings which they likely would not have acquired with a bunch of Anesthesia residents around. One even pretty much did an Appendectomy with the General Surgeon not even scrubbed and watching from a stool in the room after assisting with him all month.

Overall I would say that an academic program tends to be placed in high regard because of fellowship prospects but once you are out your reputation and skills are what will sustain you. The network from that prestigious residency/fellowship may help you get that initial job but if you spent a large amount of time doing research or seeing Zebras you may not be as adept at managing bread and butter cases as has been mentioned. Then your ability to do well in private practice in the world of referrals will not be very high,

You have to consider what you want out of your career when making these choices which to be honest a lot of 4th year med students probably don't think about since the focus is just getting into the specialty a lot of times. If you know you want to do General OP IM then it makes no sense to go somewhere that prides itself on near 100% fellowship placement or giving you a research elective in the first year.If you want to be a strong community general surgeon then Whipples and lab time also may not be important and arguably a complete waste of time just so you can have a prestigious name on your CV. If undecided getting an academic program seems to keep most of the doors we are told are important open while simultaneously appealing to our egos. I will say that it also doesn't help that in medical school a lot of advisors look down on the community programs as well and purport a stigma that if you match at one that your board scores or academic profile was not competitive.

You have to consider all your goals and personal preferences in this decision. A blanket academia is always better is a naive pre-med or medical student way of looking at it.

 

[DocDanny]

So as in your question above, you may see a lot of patients in a Community Hospital and that would prepare you to be a Hospitalist, however, you may miss out on the leading edge research and trials that may be happening and why they are happening and what the new changes in years to come may be and how something that is so ingrained in your management may be completely obsolete a few years from now.

Everyone's training is at risk of becoming obsolete, especially when they are finished. That is why we have continuing education credits.

The idea that community hospitals use obsolete treatments is false. Between going to the same conferences, and reading the same journals, I think treatment regimens are on par in both places.

Remember too, that just because there is an exciting clinical trial, that doesn't mean it is better. But if it is, it will be published in a journal that all other hospitals can read.

 

[45408]

I think for internal medicine sometimes there is benefit to going to a larger hospital that gets more referrals of complex/weird cases (which is usually a large university hospital). I'm a fellow at a university hospital and I don't "take" procedures from interns and residents. Trust me, at this point in my career putting in a central line is just not very exciting and neither is a paracentesis. So I do think it is kind of a myth to say that fellows "take" procedures from interns and residents at university hospitals, although I guess it does happen on occasion.

I'm saying it solely in the context of surgery, where a fellow definitely needs to accumulate a significant number of cases. I've been on services where the senior resident got to pick the cases that he wanted, but only after the fellow had come through and taken what he wanted.

 

[mlw03]

I'm saying it solely in the context of surgery, where a fellow definitely needs to accumulate a significant number of cases. I've been on services where the senior resident got to pick the cases that he wanted, but only after the fellow had come through and taken what he wanted.

Isn't that how it should be? I'm a fellow now, and would be quite ticked if I was regularly losing good cases to residents. The goal for a prospective resident is to go somewhere where there is enough food for everyone to eat and be merry.

 

[45408]

Isn't that how it should be? I'm a fellow now, and would be quite ticked if I was regularly losing good cases to residents. The goal for a prospective resident is to go somewhere where there is enough food for everyone to eat and be merry.

I'm not saying the fellow shouldn't get first pick, but in a field like surgery, that comes at the expense of a resident. In a field like nephrology, where I worked with medicine residents and nephrology fellows, we can all learn from the same patient. In surgery, we can't all operate on the same patient.

 

[mlw03]

I'm not saying the fellow shouldn't get first pick, but in a field like surgery, that comes at the expense of a resident. In a field like nephrology, where I worked with medicine residents and nephrology fellows, we can all learn from the same patient. In surgery, we can't all operate on the same patient.

Understood. So what's the solution, if there is one? To bring it back to this thread, coastie, how would you respond to this claim? At a huge name place like MGH that's crawling with surgical fellows, do the residents get a lesser experience as a result? Sure, they may have great looking CVs, but if they've done 200 less colectomies at the end of their residency that the guy who trained at community program X, who is better prepared to go out there and actually serve their patients with solid operative skills?

 

[koennen]

At my community hospital, we don't have to compete with any fellows for procedures, and while we see zebras, the majority are bread and butter cases. This will make me a better Hospitalist.

My hospital is a little smaller. Most of us want to do general medicine. But the ones who want to do fellowships do well. One friend got a fellowship in ID, two in heme/onc, and another got into Pulmonary/CC.

Who is this "we" and "us?" I appreciate that you have matched at this hospital, but right now you're a medical student.

 

[DocDanny]

Most of my training for the past 24 months has been in community hospitals. Including 3 months at the one I matched at.

I never said I was a doctor (8 more days till graduation). I just said its my hospital. Which it is. I've done a lot of my training there and I know everybody.

 

[KnuxNole]

Dumb question, but why are zebras only in "top" places? Is it because all rare cases flock to those hospitals?

 

[KnuxNole]

Also, the vast majority of people are unable to even get invited to interview at the "best" places, or choose not to apply there due to various reasons.

And after reading this, I feel like I might be the minority person who is not too interested in prestige. I'd rather be at a nice friendly program training to be a physician instead of a malignant and cutthroat place where people try to show they are better than others.

 

[McGillGrad]

Dumb question, but why are zebras only in "top" places? Is it because all rare cases flock to those hospitals?

Zebras tend to end up in a couple general type of places.

The first type of place is in a bad/disadvantaged/immigrant/poor neighbourhood. These places just happen to populations with crazy pathology.

The second type of place is one that is a big academic referral centre that has all of the sub-specialities and tonnes of research and that is where zebras are referred after they present elsewhere.

 

[mlw03]

Dumb question, but why are zebras only in "top" places? Is it because all rare cases flock to those hospitals?

It's more because that's where they are referred. Community hospitals/docs just don't have the expertise to deal with them, while the academic places tend to.

 

[DocDanny]

Well, depends on the zebra.

It might be very rare, but very simple to treat once diagnosed.

 

[cowme]

Also, the vast majority of people are unable to even get invited to interview at the "best" places, or choose not to apply there due to various reasons.

And after reading this, I feel like I might be the minority person who is not too interested in prestige. I'd rather be at a nice friendly program training to be a physician instead of a malignant and cutthroat place where people try to show they are better than others.

don't fall into this stereotype. There are plenty of friendly programs at the "best" places and plenty of malignant community programs

 

[Law2Doc]

don't fall into this stereotype. There are plenty of friendly programs at the "best" places and plenty of malignant community programs

Yeah I think you don't want to mix and match terms like "prestige", "best" and "friendly/malignant". A place can be prestigious and malignant, or prestigious and lousy place to train, or prestigious and friendly. It can be non prestigious and a malignant hellhole, or non prestigious but outstanding in training. You do yourself a big disservice if you try to equate these categories of terms.

 

[reno911]

This argument seems incredibly silly. There should essentially be universal agreement on these two points:

1. In general, training at a random large academic medical center is likely to be superior to training at a random community hospital.

2. It is possible that in certain instances the training received at a particular community hospital would be superior to that received at some large academic medical centers.

And there is no contradiction between 1 and 2.

 

[404958]

I think it also depends on what you are looking for. Put yourself in these two scenarios:

(1) You're working in a smaller community hospital. The neighborhood is not great, but not bad. Everyone knows each other. People don't look at your ID badge and then say hi to you... they look at your face. Security doesn't treat you like vermin. You start rounds on patients with DM, asthma, obesity, hbp, .... bread and butter stuff you might see in your real practice. You get really good at treating this. The nurses aren't terribly territorial and you perfect your blood draws, your iv lines. You look forward going to work. You round and your attendings teach you. On the weekends, your co-residents grab a burger together.


(2) You are at a large institution's tertiary care center. You see the zebras that require fundamental knowledge of physiology. You see the cases few get to see in their life times. From cardiac myxomas to alien hand syndrome, your intellect is tinkled. You see cutting edge treatments ranging from whipple's to gamma knife therapy. Modern treatment at its best. Your attendings are worried about paying the bills though, and teaching is... not a priority. The iv nurse works on her schedule. The nurses are a cliquey entity to be dealt with. every year it seems, a resident is pushed out under specious circumstances. the fellows cherry pick the awesome cases. It's not uncommon for a senior resident to barge in the room and takeover the patient. You get yelled at, and you're just not sure why.


If you've a the skin of a dinosaur and the brain of an owl, maybe #2 is looking delicious. If you're more down to earth, maybe #1.

 

[Buzz Me]

(1) You're working in a smaller community hospital. The neighborhood is not great, but not bad. Everyone knows each other. People don't look at your ID badge and then say hi to you... they look at your face. Security doesn't treat you like vermin...You round and your attendings teach you. On the weekends, your co-residents grab a burger together.

(2) You are at a large institution's tertiary care center...It's not uncommon for a senior resident to barge in the room and takeover the patient. You get yelled at, and you're just not sure why.

If you've a the skin of a dinosaur and the brain of an owl, maybe #2 is looking delicious. If you're more down to earth, maybe #1.

But the two situations are not mutually exclusive. We rotate at a private hospital here in addition to our university teaching hospital (and county hospital, and VA, and children's hospital). I can tell you I've had some lousy didactic conferences at the university hospital, and some outstanding ones at the community hospital. I can also tell you that I've developed some great relationships with hospital staff and attendings at the university hospital, while there have been some malignant personalities at the community hospital.

Both are good for their own reasons. Tough to generalize and say one is ALWAYS this, or one is ALWAYS that. I picked a residency that would give me broad exposure to many types of hospitals (see above).