Monday, January 28, 2013

Choices: University program with research or not?

I am a 4th year medical student who is going into general surgery, and I wanted to ask you a question as I'm getting my rank list in order for the upcoming match.

I've been a good student and hopefully have a lot of doors open for me for my rank list. I had a few interviews at some "top-tier" programs (more research heavy, but also big names) and plenty at very good "middle" programs. I'm pretty confident that I want to be a community surgeon when all is said and done, but I most definitely will want to do a fellowship. At this point, I think that would be in colorectal surgery.

I feel conflicted about my rank list, though. Several people have told me that it would be stupid not to rank the top-tier programs first, and part of me feels like I should go for these big names. However, at this point I don't think I want to do 2 years of dedicated research during my residency, which is a requirement at these top-tier programs. Unless, of course, colorectal fellowships are getting more and more competitive and that's what it will take to get in them.

Plus, I feel deep down that some of these middle programs actually have a better operative experience, as there are busy county hospitals (giant trauma centers) affiliated with them where I feel the residents get unparalleled opportunities to operate more and with more autonomy.

Honestly, I think I really want to rank some of these "middle" programs over the "top-tier" ones, but I keep on trying to convince myself that I want to "go-for-the-gold," as it is.

I fully plan on being productive in clinical research during my residency (I have 3 publications already) so I'll [hopefully] garner more publications during residency, but, in your opinion, are 2 years of dedicated research something that I should really be thinking about? Are more and more surgeons doing that type of dedicated research work in order to get fellowships? At the end of the day, I just want to be able to operate confidently, get the fellowship I want (no plans for surg onc or peds at this point), and help patients. Any advice or comments you have  would be extremely helpful and appreciated.

I posted this email with a bit of editing for length and confidentiality but wanted other readers to see what is going through your mind. It is a difficult decision.

Let’s take the easy part first. The 2012 colon and rectal fellowship match statistics show that there were 129 applicants for 90 positions and 73% of US med school grads matched. With three published papers (two of which are in respected surgery journals) already and probably more to follow during your residency, I can say with confidence that you will have little or no trouble obtaining a fellowship in colon and rectal surgery. Statistics are available here for most of the other specialty matches too.

Now, let’s look at your personal situation. I share your concern regarding the two major issues you raise.

If you are fairly certain you don’t want an academic career, is spending two years doing research worth it? As noted above, it is not a sina qua non for colorectal training. Also, should you change your mind and decide later that you do want an academic career, you can do extra research time in many fellowships.

Operative experience generally begins earlier and is more extensive in non-university programs. This is not just my opinion. As I explained in a blog last year, a survey showed that residents in community hospital programs were “statistically significantly more satisfied with their operative experience and less likely to worry that they will not be confident operating by themselves after they finish training than university trainees. Surprisingly, they were also happier with the level of didactic teaching than university-based residents.”

You did well in medical school, have excellent scores on USMLE Parts I and II and have less than $50,000 in student loan debt. You are in a position to do exactly what you want.

I think you will probably match at every program on your list. General surgery residency is a long and difficult time. You should pick the program that you think you will be most happy in.

I hope this helps.