Tuesday, January 13, 2015

Academic vs. community hospital for surgery residency

Here's question from a senior med student at a state school. She has excellent grades, USMLE Step 1 and 2 scores > 245, has co-authored 4 published papers, and was elected to AOA. She writes

I am looking to re-locate to a large city for residency as a number of my family members live there. I have interviewed at the large academic centers in the city as well as their community affiliates. I have also been involved in research and always assumed I would enjoy the biggest "named" institution possible. As I have interviewed, I truly feel that I would get better training (and be happier) and the academic-affiliated community programs in that city. However I have been told my several advisors at my home school that this would be "career suicide" and it would be "idiotic" not to take the best name that I have a chance at matching at. As far as fellowship, I have literally no idea what I want to do. Maybe surgical oncology, maybe transplant? Maybe vascular, maybe nothing?!

What is your insight into this? Should I seek what I perceive to be the best training/fit or should I rank the higher name academic programs for the sake of my career?

Here's my opinion. Be advised that it is strictly my opinion and may be neither popular or correct.

You should have no problem matching at any affiliated community hospital program and probably have a very good chance to match at every academic program in the city you want to be in.

I hope you have properly researched your top choices and are confident that the residents are happy and doing a lot of cases. Also you should be sure that the leadership of the program is stable. I suppose your mentors your school want you to take the academic track because that's what they did. It also enhances the reputation of the school when its students match in big name programs.

You remind me of me except I didn't have the publications you do. I took the "comfortable" choice for residency and never regretted it. I trained in the same city you are looking at. It's a great place to live.

I see it this way. Suppose after a couple of years in a community program, you decide you want to be an academic surgeon. After you residency, you can always take a fellowship in something at an academic medical center.

But if you go with a university program and are miserable, then what do you do? Five years (plus a year or two of research) is a long time to be miserable.

I went into more detail about this in a post three years ago.

Listen to your heart. Go for the place that you feel most comfortable with.

I strongly suggest ranking all of the programs you feel you can live with—just in case.

Good luck and let us know how it turns out.

Readers, feel free to disagree or agree as you see fit.


  1. I am floating along in the same boat as the above-mentioned student. Step1/2<245, AOA, but I do not have many pubs. I am currently trying to decide between a large academic program and a community program I had the fortunate experience of rotating at. I KNOW that the program I rotated at excels in all aspects of surgical training and have had 100% board pass-rate for upwards of 15 years. I do not know if I would like to pursue academics, but I do know I want to operate my tail off during residency. Luckily I have until 2/25 to decide!

  2. As counterpoint - If you know for sure that you want a community job straight out of residency, or you don't want a competitive fellowship, by all means I would consider a good community-based program. I've counseled a number of med students in that direction. If you are thinking about the possibility of a more competitive fellowship or have a potential interest in an academic career, you should absolutely look at an academic program. Remember that the vast majority of surgery residents are now doing fellowships. Also remember that it can be difficult to get a job in a big city without having a niche, usually gained through fellowship specialty training.

    As a fellowship director of a MIS program, I can say that you are much more likely to find a spot at a competitive fellowship coming from an academic institution. Realistically speaking I (and other fellowship directors) look at applicants through a lens of academics. I look at a residency program's reputation and at letters from surgeons that I know through big organizations like the ACS or SAGES, who tend to also be academics. I also look at a track record of publications and participation in national meetings. These items on a CV are harder to come by in community programs.

    I am a bit concerned that you worry about being unhappy at an academic program. That suggests to me that you are looking at the wrong residency program. The old reputation of academic programs as being clinically inferior or malignant should be a thing of the past. There may still be a few programs like that out there, but speaking from my own experience at 2 institutions, it is possible to find an academic program that is welcoming, considerate of residents, provides excellent operative and clinical experience, and also provides an academic rigor with opportunities to do research.

    I think that Skeptical Scalpel is being a bit optimistic about the ability to move from community practice to academics - I know of only one surgeon that has done that. He worked in community practice for several years before switching to academics. He had trained in an academic program, did a research fellowship, and still had to volunteer as a community surgeon at the VA for several years before getting a full-time position in academics.

  3. Lucid, thanks for commenting. Good luck with your decision.

    Andrew, I appreciate your comments but I must respectfully disagree. Let me clarify one thing first. I wasn't talking about someone going into community practice. What I meant to say was if she take a community program and while a resident decides she wants to be an academician, she could always take a fellowship at an academic program. The part I disagree with is that it is hard to do that. Below are links to 7 randomly selected community programs of various sizes and reputations. One of them, Danbury Hospital, has only existed for 4 or 5 years. Just look where their residents have done fellowships. With her record in med school, she will be able to find a good academic fellowship if she has a change of heart.

    Here are the links:





  4. to better answer the medical students question I would like some more clarification. Did she do research because she really likes it? Or did she do it because it boosts her resume? Can you create a list of traits and how important they are in how you chose your future job? Pick amongst (location, pay, research requirement, specialty)

    Since you don't know what you are going to do, the safest option is to go to a brand name academic center in the city you want to work in (where your family is). This way you preserve your pedigree and retain the option to work in the city you want. A brand name academic residency also enhances your fellowship options / interviews. what do you think your odds are of getting into peds surg from a community vs academic center? If you know you are going into transplant, you don't even need a US surgical residency :)

    I think its important to understand that there is no way of assessing how good of a surgeon someone is unless they've done a lot of work and have alot of outcomes data to prove it. There's a saying ... "its not how much you make at Hopkins, but how much you make at the job AFTER Hopkins" Remember, even if you get a 90+ absite every year, have great letters, and a ton of publications but come from a community center ... there will be another kid sitting right next to you on fellowship interview day with the same credentials but from an academic center. the fellowship will take the brand name kid unless one of your letters is from someone famous or is personal friends with program you want to go to.

    surgical residency sucks no matter what. its the cost of doing business. I think you should go to academic residency in city you want to be in. then get whatever fellowship you think will train you the best in. then you will be in the best position to choose what kind of job you want.
    I didn't train at an academic center but I can only speculate the "cons." People complain about fellows and even "superfellows." Understand that the hard operations really require a skilled second set of hands. The surgical attending who wants a good outcome is gonna prefer a superfellow over a fellow, and a fellow over a chief resident.
    You are probably going to be forced to do some research at academic residency but this will be good for you. Its like your parents telling you to eat vegetables.

    finally, I hope its not too late but please consider Baylor University Medical Center in Dallas for surgical residency. I really saw it as a surgical residency utopia. Half of time spent at BUMC with high skill, major metropolitan area, teriatry care surgeons. Half at JPS :) They have residents not because they need residents to do certain tasks but because they take pride in it. Attendings did discharge summaries with the residents. You won't find this at many places. Its a community tertiary care center where they have less of their grads going into fellowships than the national average because they come out feeling so well trained. This is also a community program that does send people into pediatrics/surg onc...etc. because the attendings there are so well known. More importantly they particpate in the society (ACS) as well and their letters will mean something. Then when you graduate you will a known product and can stay to work in Dallas, a great city to be in. NO STATE TAX. TORT REFORM. then again it may be hard to get an abortion in that state if that is relevant. also its okay to walk around with an assault rifle in the street. cant have it all.

  5. Thank you for share this informative post.