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.

A non-US citizen international student's chances of matching in surgery

"Brian," a medical student in Egypt, wrote me about obtaining a surgical residency in the US. Due to space limitations, I have edited the email. He will take USMLE Step 1 soon. He has no green card.

He read a previous post of mine about a US citizen international medical graduate (IMG), but still had several questions.

He asked what qualities separate an applicant matching in a categorical position from one matching in a preliminary position?

"Categorical" means, barring any performance or behavior issues, the resident will complete a full 5-year general surgery residency program.

What do students do on third-year surgery rotations?

A woman who has been accepted by a few medical schools and is trying to decide which one to choose asks

What extent of involvement should be expected for medical school surgery rotations? I have enjoyed shadowing general surgery and feel that a field involving some procedure may end up being my fit, or at the very least something to enjoy in medical school. I am curious as to the type of participation in procedures (suturing/closing for example) that is typically allowed as a student versus that allowed and expected as a resident. 

In most third-year surgery rotations, students can do some suturing of skin and maybe lacerations in the ED provided the student has practiced knot-tying and using instruments outside of the OR. Opportunities to suture in the OR are fewer these days because of skin stapling and the use of glue, which are both faster than suturing. Hardworking and interested students are far more likely to be rewarded with things to do by residents.

Otherwise, there's a lot of camera holding for laparoscopic cases and retracting for open cases. Students used to do H&Ps and write postop orders but the electronic medical record has curtailed those activities greatly.

Medical school has changed a lot over the years. As a fourth-year student in the early 1970s, I placed many subclavian central venous catheters—some of which were unsupervised. Six years ago, I was about to let an intern place a subcutaneous chemotherapy port in the OR. It was halfway through the academic year. I asked her how many subclavian catheterizations she had done. She said she hadn't done any but had seen one.

I can't say whether that lack of experience is common to most current med students, but I think it may be.

Of course, residents get to do much more as they progress through the years. Residents in community hospital programs tend to do more cases during their first 2 years and often will have performed more cases over the 5-year course of residency training than those in pure university based programs. Of course, there are exceptions.

If this is really a major factor in your decision-making process, I suggest you try to talk to some students at the schools that you have been accepted by and see what they have been able to do during their third-year surgery rotations.

You will probably find that students who do third-year clerkships at community hospitals affiliated with med schools get to do more hands-on work too.

The same goes for those applying to residency. If you really want to know what goes on, talk to some of the residents who weren't chosen to meet the applicants on interview day.

I hope some of our readers will comment.

US citizen IMG surgery prelim resident needs advice

Maicon, a non-designated preliminary general surgery resident, writes

I read with interest your post on matching rates for international medical graduates. I am a US citizen IMG, born here, but grew up (since 2 years of age) in another country and completed my medical school there a few years ago.

My USMLE scores are step 1 - 235, step 2 - 251, Step 2CS and Step 3 passed on first attempt. Knowing that general surgery was hard to get, I worked (unpaid) in the surgery department at a large Northeastern academic center.

I got a prelim spot at a decent program with a program director I respect. I worked my ass off, studied hard, and got in on research projects early.

ABSITE: 1st year - 90th percentile (highest in our class), it got me a 2nd year at the same program, 2nd year - 79th percentile.

Did a ton of research with a couple of publications and presentation, and won a teacher award by med students. My evals were good, and I got great recommendation letters. I thought I covered my bases.

My program doesn't have a spot for a 3rd year and am unable to find one, despite the good intentions of my mentors. It is frustrating that, try as I might, I am still out of a residency on June 30th of this year.

Should I continue to pursue the surgical field, do a research fellowship which I have seen from previous blogs/articles doesn't help much, do a subspecialty fellowship (Cardiothoracic ICU/critical care/Burns), or switch to medicine or FP? From, your previous posts, I feel you will probably suggest to switch.

Thanks for reading my blog and for your email. I am sympathetic to your plight. I've seen it many times.

I wish I was still running a program. It sounds like I could have used someone like you.

If you have no financial or other pressure to get on with your life and are young enough, I suggest you take a fellowship in one of the clinical areas you mentioned such as critical care. An accredited one is preferred because you could take the board exam when you finally get through a 5-year GS program. Even a non-accredited fellowship in a clinical area is better than doing research. Your chances of obtaining a categorical spot are enhanced by taking care of patients instead of test tubes.

 If you do a good job with the fellowship, you might be able to sneak into a categorical slot somewhere. Make sure you take the ABSITE again too. The scores are really important.

Have your program director keep an eye on the program directors' list serve. Categorical slots open up frequently—even into June.

Good luck.

Help! My friend didn't match in orthopedics ... again

Maicon [not his real name] writes

My friend wanted to be an orthopedist, but his grades and USMLE scores were just average for medical school—Step 1 was 215. He applied last year, got some interviews but didn't match. He started a research fellowship in ortho at an academic center and re-applied. I tried to tell him to defer applying until he finished the fellowship so he could have something to show for it other than, "I started a fellowship and working on blah blah blah." This year, he got fewer interviews and failed to match again. During all this, I had advised him to also apply to general surgery, but he always resisted. He now has decided to try for an unfilled general surgery preliminary position.

I realize this is an elaborate discussion however you would be doing a major service for many applicants of this kind who have nothing to go on other than delusions or conspiratory paranoia.

Sad to say, but this happens every year.

The advice to do a year of orthopedic research was misguided. He has just wasted a year of his life.

I'm not sure what goes on in orthopedics. However, in a recent post on how general surgery program directors select residents, I noted that previous research experience was extremely low on the list of criteria as was having done a preliminary general surgery year.

I wonder how many who do a research year succeed in getting an orthopedic residency position. My guess would be less than 5%, if at all.

He should be honest in his application for the general surgery non-designated preliminary position. The program directors will know the truth anyway. The good news is that there are over 450 unfilled positions this year and not enough bodies to fill them.

The bad news is that these positions can be dead ends in many cases. That is, your friend could do a year or two of preliminary surgery and then have no access to a third-year categorical spot. Another issue is that in some programs, non-designated prelims are treated like second class citizens by being given all the scut rotations.

There is some hope though. Here's a paper that found an amazing rate of success for non-designated prelim surgery residents obtaining categorical positions, but it's from Mass General. Abington Memorial Hospital reported surprisingly good outcomes. Yale's results weren't quite as good. UC-Denver also had some mixed results. There could be some publication bias here. Programs with dismal records of placing prelim trainees may not have chosen to report their experiences.

If he does obtain a preliminary spot, he must work very hard and do very well on the general surgery in-training examination in the hope that someone drops out or is cut from a categorical position and that he will be selected to replace that individual. If not, he will chalk up one or two more wasted years.

A backup plan for a different specialty career should be in mind in case he is unable to eventually secure a categorical general surgery position.

My feeling is that if an applicant doesn't match in a dream specialty, he should forget about a year of research, scrap that dream, and move on.

As always, comments are welcome.

A UK Med Student Discovers Surgery, Has Questions

Gareth (not his real name) writes

I came across your blog a few days ago and I have been reading it since. I am a third year medical student studying in the UK. I am writing to you because I would be grateful if I could get some advice. I have always wanted to become a doctor, since I was veryyyyy young, but I never ever considered a career in surgery. Before medical school, I believed that surgeons were like butchers, not capable of any human attachment for the patient etc etc. I believed I would not be able to bear the responsibility to cut someone open given the fact that I am a very emotional person. However, my perspective changed when I was in the OR and saw my first surgery. It was a coronary bypass surgery and I loved it, I loved the idea of making the patient better in such short time and the fact that the surgeon was the one responsible for it, I suppose it must be very satisfying. Therefore, I have started to consider a career in surgery, however, I am still very unsure of whether I have the right personality type and skills to become a surgeon. I still tend to get very attached and moved by patients' stories and experiences and I don't know whether that would help me detach myself from the patient whilst operating. Also, most surgeons seem to be extremely confident and outgoing whereas I tend to be shy and not confident, even though I'm quite good academically. So I am really confused right now. Also, I have never had great hand skills, even though I took some introductory surgical skills courses and they went quite well. I seem to get a bit of tremor when I do practical stuff though, I guess that's because I get nervous. 

I'd like to ask you one more thing. If I do decide to go for a career in surgery, is there any point for me to try and take the USMLE and apply for a US residency after graduation? I heard surgery it's really competitive, I guess many schools don't even accept international applicants?

Thank you very much for your time and dedication. I admire the passion that you show.

Thank you for reading my blog and for writing. I am glad that you have realized what a rewarding career surgery can be.

First let's talk about the "surgical personality." There was a time when most surgeons could have been categorized into a couple of personality types. Those days are gone. Now that 40% of all surgical residents are women it is no longer necessary to be a certain type of individual. I know many surgeons who are quiet, thoughtful and introspective. You need to dismiss any thoughts about your personality type being incompatible with a career in surgery. Also it is not a bad thing for a surgeon to identify with and become attached to his patients.

The next myth is that one must have great dexterity to become a surgeon. In the old days some residency programs use to screen applicants by making them build model airplanes. I don't believe anyone still does that. Now it seems that video game skills are much more important since so many procedures are done laparoscopically. I believe that anyone can become a more than decent technical surgeon through practice. We all get nervous. This is a real person you are operating on. I have written that there is more to surgery than manual skills. It is very important to know who to operate on and when to operate on them as well as who not to operate on.

I have written before about the decreasing chances of graduates from non-US medical schools obtaining residencies in the United States. US medical schools are expanding their class sizes and a new schools are opening. It is not even clear that all us graduates will be able to obtain residency positions in the future. The most recent statistics from the match show that only about 5% of non-US citizen graduates of foreign schools matched into categorical general surgery positions. However, I do not believe you have anything to lose by trying. You will need to get an excellent score on the USMLE and of course, have good grades and recommendations. Although it is difficult, some trainees from the UK have been able to find fellowships in the US. I do not know how easy that will be in the next few years.

Good luck

Are program directors the reason that surgical residency training is a mess?

A resident writes: "You have been a program director (PD). I read your article about residents not being confident about surgical skills and you conveniently blamed resident work hours limits/resident work ethic for this. I ask you how come PDs are not responsible for the training they provide? How can they get away with telling residents/fellows on what the residents/fellows can say/write on evaluations that accredit the program? How can they get away without providing adequate training/exposure in lap/robotic surgery? How come we don't teach surgeons how to teach surgical skills? Just because one is a good surgeon does not mean they can teach surgical skills to others. After all Michael Jordan was a great basketball player, but that does not necessarily imply he would make a good coach. In fact I would argue that average basketball players make better coaches."

 

Great questions. Let's see what I can do to answer them.

I "conveniently blamed resident work hours limits/resident work ethic" for the lack of confidence in their skills that >25% of general surgery residents have. That problem was not created by program directors. Most PDs hate it. It certainly is a contributing factor to the lack of resident confidence.
We are responsible for the training we provide. We must sign a form attesting to the competence of our graduating residents. I cannot speak for current PDs, but I felt very responsible for the residents when I was a PD.

I never told a resident what to write on an evaluation. I understand that may happen, but the evaluations are submitted on line anonymously to the accrediting body, the Residency Review Committee for Surgery. The residents are free to say whatever they want and no one will be able to trace it back to an individual. In my experience, the residents did not hold back on their complaints.

I agree with you that we are obviously not training residents well enough in some areas such as advanced laparoscopic surgery. That is difficult to understand and explain. It must be true because so many graduates of five-year programs feel the need to take extra training. I think it is somewhat harder to teach minimally invasive surgery. I always felt I could control what the resident was doing during open operations; for laparoscopic procedures, not so much. But we should be doing a better job in that area.

And it's not just laparoscopy or the American College of Surgeons wouldn't have established "Transition to Practice" fellowships. See my previous blog about this. There is also the problem of too much supervision which I mention in that blog.

I have news for you. In most cases, surgeons are not taught how to teach anything, let alone surgical skills. For many years, it has just been assumed that any surgeon (or any doctor in any specialty) is an excellent teacher. Of course, this is not so.

However, teaching is not particularly valued or rewarded an academic medicine. On the other hand research is, especially research that brings in grant money.

Teaching is also a problem in community hospital programs because attending surgeons are busy trying to stay afloat financially.

I agree with you that Michael Jordan and most other superstars of sport would not make good coaches. It may be similar in surgery. I don't think that has been investigated, nor is such a study likely.

In case you haven't read any of my previous posts (search "surgical education" on the Skeptical Scalpel blog) on this subject, I am pessimistic about the future of surgical education.

A med student with issues wants to be a surgeon

An osteopathic medical student writes that she is older than most students, failed a course in her first year of med school, had to take the COMLEX (osteopathic equivalent to USMLE) several times before passing. She has earned good grades in her third-year rotations. 

She said, "I found your blog one night earlier this week while doing research on obtaining a surgical residency. After reading your blog, I thought you might be able to help. What can I say to programs and put in my application to make me stand out as someone who they would value and honestly consider?"

I appreciate your reading my blog. As you have correctly pointed out, you have some problems. I hope you can handle the truth (from the movie "A Few Good Men").

1. You are an osteopathic student, which may adversely affect your ability to obtain a general surgery residency by a little to a lot, depending on where you  apply.

2. You are a non-traditional student (not so bad) but your age of 33 is another issue. Should it matter? No. Does it matter? In my opinion, yes.

3. You had some trouble in the first year of school. That is usually a red flag, and many program directors would not get past that part of your dean's letter and transcript.

4. You have "struggled with the COMLEX and have had to take it multiple times" and you have not taken the USMLE.

With the disclaimer that this is strictly my opinion and I cannot say how you would be viewed by other PDs, your chances of matching to a categorical position in general surgery are slim. 

What can you do to improve the odds? Here's what I would suggest.

To counteract the COMLEX issue, try to take at least USMLE Part I and do very well on it.

In your personal statement, you should own up to the concerns just as you did in your email to me except that you need to condense everything into a much shorter document. You should emphasize that you have conquered these shortcomings. You need to find med school teachers, particularly surgeons, who know you well and are willing to write exceedingly strong letters of recommendation. A letter from someone who a PD might have heard of would not hurt.

You then have to wait and see if you are invited for any interviews. If you are, you need to impress everyone with your charm, work ethic and intelligence.

You also need a "Plan B." Would you take a non-designated preliminary slot hoping for someone to falter or quit so you could transfer into a categorical position? It is risky because you might end up wasting a year or two and have to take a residency in something else anyway. That's not a big deal if you are 26 when you graduate from med school, but for you it would be.

Another option would be to do an internal medicine residency and specialize in GI or cardiology which are procedure oriented. It's not surgery, but it might be satisfying and certainly would be easier to achieve. 

You didn't mention whether you had significant student loan debt or not. That needs to be factored in if you are considering the non-designated prelim choice.

I hope this helps. Let me know how it turns out.

Good luck.