Unhappy With Placement for Rotations

[Drrrrrr. Celty]

I would argue that there are gems in the stuff they have to teach you. It was actually a community hospitalist who thought me about post-pit/DI's oscillating polyuria. The stuff that's missing is what you have to know if someone's gotten CAR-T treatment and how to treat critically ill cirrhotics and end stage CHF'ers about to get transplanted/LVADs, etc., which can actually be a con because a lot of that management is made by big honcho subspecialists without much resident involvement.

Some residents get the latter taught to them instead of the basics like how to manage HF and are glorified scribes to the subspecialist masterminds.

I think there's a lot of training to be gained in every setting. My program is split between multiple hospitals one being a more community place and the other being a more traditional referral center. I gained far more as a primary in the community program because I did it all myself, where as at the referral center I was very sternly encouraged to consult and for the more complicated stuff like structural heart or hepatology I barely even put in orders at all. It felt almost as if I was there to place a diet, replace magnesium, and just observe as others managed things. It felt almost boring.

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[Redpancreas]

I think there's a lot of training to be gained in every setting. My program is split between multiple hospitals one being a more community place and the other being a more traditional referral center. I gained far more as a primary in the community program because I did it all myself, where as at the referral center I was very sternly encouraged to consult and for the more complicated stuff like structural heart or hepatology I barely even put in orders at all. It felt almost as if I was there to place a diet, replace magnesium, and just observe as others managed things. It felt almost boring.

Best of both worlds! On the same page about the bolded...at least until you become the specialist.

 

[genessis42]

I think this problem of not getting enough rotations w/ Residents is common for all DO schools. The rotation lottery at my school often turns students against each other -.-

 

[BorntobeDO?]

Wait, wut? And the class has to buy the school a gift?

A lump of coal would suffice IMO.

 

[BorntobeDO?]

I mean to he fair I had already done a lot of that in 3rd year, but I knew fellow med students in my same school that had done none of it by mid 4th year. In all honesty, you learn it either way in intern year, it's just a matter of how steep that learning curve is.

Having rotated with and taught MD students, my impression is that some of their experiences are just as variable as ours were, but they're more organized with it, so even if they don't have great experiences on every rotation, everyone seems to get at least some good experiences over the course of 3rd year to look better in 4th year. The weak students are still weak and strong students are still strong.

Now that all said, I will say for the first time I've been working more with interns and I've noticed a difference between the ones with COVID era rotations and those thay had more normal rotations. They're taking a bit longer to adapt, and things I would have expected to be obvious or second nature are not as such. Maybe I'm just getting too far out from that point in training, but I never expected to truly feel a difference, and I'm surprised that I do. I think they're getting there, but it is definitely taking more time than before. I imagine next year might be a bit worse, but then things will get back to normal.


The dirty secret is that this is literally all of medicine, and it doesn't end as an intern, senior, or attending. We know so little, but just slightly more than the person behind us. You basically live off of knowing your limitations and when you need to ask for help. The intern asks the senior, the senior asks the attending, the attending asks the specialist, the specialist asks... more specialists or subspecialists or senior faculty or mentors. Everyone just has slightly more information than the next, but builds off of the confidence of each person. It's why in complex cases, specialists always insist on more tests and more consults of other specialties, because they have no idea, and they're hoping a bunch of well educated people will come to a consensus. And when it happens it's awesome and you can see how excited literally everyone involved is. You don't realize this as a med student or intern, you just assume everyone just knows everything.

Covid era interns are very variable in my experience as well. I had one intern that had managed to avoid all inpatient rotations 3rd and 4th year due to covid. She was just as bad as that sounds.

 

[Drrrrrr. Celty]

Covid era interns are very variable in my experience as well. I had one intern that had managed to avoid all inpatient rotations 3rd and 4th year due to covid. She was just as bad as that sounds.

I have one intern like that. It was not good.

 

[DrWBD]

If your school has a rotation lottery and doesn't allow any swaps, your school is run by people who don't give a crap about you as a future physician.

 

[calivianya]

If your school has a rotation lottery and doesn't allow any swaps, your school is run by people who don't give a crap about you as a future physician.

I’m not sure swaps are any better.

I am at a school that has a lottery and allows swaps. Naturally, lots of money exchanged hands. You wonder what happened when you watched lower SES students be excited about their site then mysteriously have a different site… until you hear the rich kids talk about paying five figures for a new rotation site. $20k was the high score I heard in my year, directly from the person who paid the $20k. I don’t blame the poorer kids, it’s hard to resist $20k in cash when you’re living on a student budget.

As someone who is living off student loans, though, I couldn’t buy a better rotation site off of anyone. Being completely real, since I got the site that most people rank dead last, I’m sure it would have been way more than $20k to get rid of my site if anyone was even willing to swap at any price point at all. I can’t help but be of the opinion that more things that allow rich people to take a dump all over everyone that didn’t grow up wealthy isn’t all that great.

 

[MDMechEngr]

I’m not sure swaps are any better.

I am at a school that has a lottery and allows swaps. Naturally, lots of money exchanged hands. You wonder what happened when you watched lower SES students be excited about their site then mysteriously have a different site… until you hear the rich kids talk about paying five figures for a new rotation site. $20k was the high score I heard in my year, directly from the person who paid the $20k. I don’t blame the poorer kids, it’s hard to resist $20k in cash when you’re living on a student budget.

look on the bright side, it beats the hell out of the poor kid drawing a ****ty site and the rich kid drawing a top site, but I get your point.

 

[homunculusus]

I’m not sure swaps are any better.

I am at a school that has a lottery and allows swaps. Naturally, lots of money exchanged hands. You wonder what happened when you watched lower SES students be excited about their site then mysteriously have a different site… until you hear the rich kids talk about paying five figures for a new rotation site. $20k was the high score I heard in my year, directly from the person who paid the $20k. I don’t blame the poorer kids, it’s hard to resist $20k in cash when you’re living on a student budget.

I don't see an issue with that if the school allows it. I know someone who wanted to be closer to their fiance and offered $150k to swap residency spots (same specialty) but the other person declined since they didn't need the money and it's also probably against NRMP rules.

At my school, some of the desirable spots are within 10-15 min of where many students are from. So they would easily save $20k on living expenses if they got those rotations. If they offered $20k to buy/swap for that spot, it's actually a bargain to them. If I was in the seller's shoes I'd demand minimum $35k to make it worth my while - because I could also save $ living at home. The $35k is more like $15k when you consider living costs vs living at home (in this scenario)

I've been around a lot of wealthy people and once they reach a certain level of financial security money just becomes a tool to buy time/convenience. I know students who rented apartments in multiple cities and rarely lived there, just used them as a place to crash occasionally (more convenient than renting hotel/airbnb each time they're in town). I know someone whose parents rewarded them with a $60k car after passing a class on the third attempt.

If you end up as a physician couple bringing in $600k+/year you'll start to value time/convenience more. 15 years from now you'll take the $800 flight with comfy seats over the $120 spirit flight with a 2hr layover and crappy seats

 

[calivianya]

If you end up as a physician couple bringing in $600k+/year you'll start to value time/convenience more. 15 years from now you'll take the $800 flight with comfy seats over the $120 spirit flight with a 2hr layover and crappy seats

This isn't even close to comparable. Every seat on a plane gets you to the same place regardless of where you're sitting.

I don't want derm, but I am going to pick derm as an example. Wanting derm and buying a spot at a place with a derm residency buys you exposure to a residency program, the ability to network with the PD, and research opportunities with the residency team within the field of dermatology. In contrast, getting assigned to a site with no dermatology residency and no means to buy your way into a hospital with dermatology means you can't make any of those connections. You can't tell me people in these two situations are going to have the same odds of ending up in dermatology - we both know they won't. Some of my school's sites have >5 residency programs and some have zero of any kind, not even community family medicine, so you can extrapolate this example into every single specialty possible.

I think that all students who enter med school should have an equal chance to match for residency, more or less, if they put in equal effort. Having some people buying an entire year of residency program exposure when others won't interact with a single residency program until they do aways during fourth year destroys any illusion of equal footing.

 

[homunculusus]

This isn't even close to comparable. Every seat on a plane gets you to the same place regardless of where you're sitting.

I don't want derm, but I am going to pick derm as an example. Wanting derm and buying a spot at a place with a derm residency buys you exposure to a residency program, the ability to network with the PD, and research opportunities with the residency team within the field of dermatology. In contrast, getting assigned to a site with no dermatology residency and no means to buy your way into a hospital with dermatology means you can't make any of those connections. You can't tell me people in these two situations are going to have the same odds of ending up in dermatology - we both know they won't. Some of my school's sites have >5 residency programs and some have zero of any kind, not even community family medicine, so you can extrapolate this example into every single specialty possible.

I think that all students who enter med school should have an equal chance to match for residency, more or less, if they put in equal effort. Having some people buying an entire year of residency program exposure when others won't interact with a single residency program until they do aways during fourth year destroys any illusion of equal footing.

Have you ever flown spirit vs say, delta? Spirit has less space (cramped), seats don't recline, no charging ports, snacks cost money, etc. Point being - money can provide comfort/convenience.

Back to the main discussion. Those pursuing derm, ENT, ophtho, ortho, etc generally know what it takes and work towards it from day 1. By the time they start rotations the "meat" (step 1, research/pubs, grades, etc) of their application is mostly complete. If they want derm they can audition at many places. It's not like someone rotating at IM can run across to the derm department and somehow hang out there for a few hours and impress them so much they'll RTM (rank to match) when the time comes. You generally have the chance to "impress" when you audition. Many also take a research year for such specialties

I understand your frustrations and many of my DO friends had similar complaints. However, for the vast majority of med students (which are MD) their assigned rotation spots has virtually little affect assuming they audition for their desired specialty. Many students from my school consistently match derm and ortho despite rotating at the "community sites" where there are only IM/FM/OB/Psych departments.

Again, I understand that DOswant every ounce of exposure and networking you can get, but life isn't fair and not everything can be divided equally. To your last statement - what exactly does "equal effort" mean? Sometimes I study for 10 hours (no phone/distractions) but still have a weaker grasp than say "Joe" from my small group who studied for 6 hours. Does that mean I am somehow "deserving" of the same exam scores just because I invested the same # of hours? It is also uncommon for people to "buy" residency program exposure. It happens (they pay a classmate to swap) but it hardly has any major impact.

Wait till you see the level of nepotism in medicine.Should children of doctors also be barred or penalized in some way? The dean's child at my school did not get preferential treatment, didn't get the "best" pre-clinical assignments or clinical rotations. Not everyone takes advantage even if they have the ability to do so.

But I also know several children of doctors who matched at places above their caliber because their parents are attendings within the dept/hospital. Such drastic examples that it can't just be "they worked hard" and it is definitely nepotism at play. For example, a caribb grad matched EM among a roster of ALL USMDs (dad is an attending there). A DO with <500 COMLEX, and a few red flags, matched a semi-competitive specialty while their coresidents all had 600+ because that person's dad is on the faculty. I'm OKAY with all of that - it's how the world works. It's in every industry, and it's even worse in other industries than it is in medicine. Work hard and worry about yourself

 

[calivianya]

Have you ever flown spirit vs say, delta? Spirit has less space (cramped), seats don't recline, no charging ports, snacks cost money, etc. Point being - money can provide comfort/convenience.

Back to the main discussion. Those pursuing derm, ENT, ophtho, ortho, etc generally know what it takes and work towards it from day 1. By the time they start rotations the "meat" (step 1, research/pubs, grades, etc) of their application is mostly complete. If they want derm they can audition at many places. It's not like someone rotating at IM can run across to the derm department and somehow hang out there for a few hours and impress them so much they'll RTM (rank to match) when the time comes. You generally have the chance to "impress" when you audition. Many also take a research year for such specialties

I understand your frustrations and many of my DO friends had similar complaints. However, for the vast majority of med students (which are MD) their assigned rotation spots has virtually little affect assuming they audition for their desired specialty. Many students from my school consistently match derm and ortho despite rotating at the "community sites" where there are only IM/FM/OB/Psych departments.

Again, I understand that DOswant every ounce of exposure and networking you can get, but life isn't fair and not everything can be divided equally. To your last statement - what exactly does "equal effort" mean? Sometimes I study for 10 hours (no phone/distractions) but still have a weaker grasp than say "Joe" from my small group who studied for 6 hours. Does that mean I am somehow "deserving" of the same exam scores just because I invested the same # of hours? It is also uncommon for people to "buy" residency program exposure. It happens (they pay a classmate to swap) but it hardly has any major impact.

Wait till you see the level of nepotism in medicine.Should children of doctors also be barred or penalized in some way? The dean's child at my school did not get preferential treatment, didn't get the "best" pre-clinical assignments or clinical rotations. Not everyone takes advantage even if they have the ability to do so.

But I also know several children of doctors who matched at places above their caliber because their parents are attendings within the dept/hospital. Such drastic examples that it can't just be "they worked hard" and it is definitely nepotism at play. For example, a caribb grad matched EM among a roster of ALL USMDs (dad is an attending there). A DO with <500 COMLEX, and a few red flags, matched a semi-competitive specialty while their coresidents all had 600+ because that person's dad is on the faculty. I'm OKAY with all of that - it's how the world works. It's in every industry, and it's even worse in other industries than it is in medicine. Work hard and worry about yourself

Still, Delta and Spirit get you the same place. Coincidentally, I've been a Delta Amex card holder for years... I am definitely not misunderstanding you about the conveniences because I'll happily pay the extra fees to keep my yearly companion certificate and my zone 1 boarding. I just disagree that rotation placement is a convenience issue.

I agree that nobody's popping over to derm during IM rotations, but many schools allow electives during third year, which is a great way to go ahead and start getting LORs during third year. If you have to do electives at your core site and your core site has no dermatologist at all, let alone a derm residency program, that's a major disadvantage. I also know people who bent the rules slightly for their intended specialties - ortho hopeful doing ortho for the second surgery rotation for example (we are supposed to do two general surgery rotations), so there are ways to get exposure during third year and gain access to mentors that can write letters for you if you are somewhere that these specialties exist.

Even you saying "community sites" and listing four residency programs is different than the positions my classmates are in. I have classmates who had an entire year of outpatient rotations for third year (partially d/t COVID, but still), and classmates who say they never once wrote notes in an EMR. I doubt someone who has never presented on rounds and/or hasn't written a note in an EMR before is going to impress at an audition where they are doing these things for the first time ever in med school, regardless of board scores or research. You really need a couple of rotations with a residency program of any kind to lock those skills down, and when the only reason you end up with a site that has residency programs is because you opened your wallet, it's hard not to refer to that as "buying" residency exposure for me.

Equal effort was definitely the wrong way to put it, which is my bad. Equal chance is more of what I meant - similar quality of rotations, similar standards, and similar grading metrics within a class. Med schools in general seem to do an awful job of this regardless of whether the school is MD or DO.

I do know there's a lot of nepotism in medicine; I worked in healthcare for years before medical school and worked in other fields prior to working in healthcare, including in management positions where I was responsible for hiring and firing. I'm never going to be okay with nepotism, I hope. I have certainly tried my hardest to be fair and not give anyone preferential treatment any time I've had a power differential over someone else, but that's just me. Do we need to bar children of doctors? Absolutely not, but they should be held up to the exact same standards and treated the same as anyone else.

But this has gotten way away from the original topic anyway, so I'd rather not continue to derail the thread. I'd be happy to continue via PM if you would like.

 

[FutureDoctor5000]

Still, Delta and Spirit get you the same place. Coincidentally, I've been a Delta Amex card holder for years... I am definitely not misunderstanding you about the conveniences because I'll happily pay the extra fees to keep my yearly companion certificate and my zone 1 boarding. I just disagree that rotation placement is a convenience issue.

I agree that nobody's popping over to derm during IM rotations, but many schools allow electives during third year, which is a great way to go ahead and start getting LORs during third year. If you have to do electives at your core site and your core site has no dermatologist at all, let alone a derm residency program, that's a major disadvantage. I also know people who bent the rules slightly for their intended specialties - ortho hopeful doing ortho for the second surgery rotation for example (we are supposed to do two general surgery rotations), so there are ways to get exposure during third year and gain access to mentors that can write letters for you if you are somewhere that these specialties exist.

Even you saying "community sites" and listing four residency programs is different than the positions my classmates are in. I have classmates who had an entire year of outpatient rotations for third year (partially d/t COVID, but still), and classmates who say they never once wrote notes in an EMR. I doubt someone who has never presented on rounds and/or hasn't written a note in an EMR before is going to impress at an audition where they are doing these things for the first time ever in med school, regardless of board scores or research. You really need a couple of rotations with a residency program of any kind to lock those skills down, and when the only reason you end up with a site that has residency programs is because you opened your wallet, it's hard not to refer to that as "buying" residency exposure for me.

Equal effort was definitely the wrong way to put it, which is my bad. Equal chance is more of what I meant - similar quality of rotations, similar standards, and similar grading metrics within a class. Med schools in general seem to do an awful job of this regardless of whether the school is MD or DO.

I do know there's a lot of nepotism in medicine; I worked in healthcare for years before medical school and worked in other fields prior to working in healthcare, including in management positions where I was responsible for hiring and firing. I'm never going to be okay with nepotism, I hope. I have certainly tried my hardest to be fair and not give anyone preferential treatment any time I've had a power differential over someone else, but that's just me. Do we need to bar children of doctors? Absolutely not, but they should be held up to the exact same standards and treated the same as anyone else.

But this has gotten way away from the original topic anyway, so I'd rather not continue to derail the thread. I'd be happy to continue via PM if you would like.

I am pretty sure it's now a accreditation requirement that at least one rotation in third year is with a residency program or with residents? How did people go with doing all outpatient for the entire year?

 

[homunculusus]

I am pretty sure it's now a accreditation requirement that at least one rotation in third year is with a residency program or with residents? How did people go with doing all outpatient for the entire year?

I can only speak to what my friend's told me but their schools essentially looked the other way especially during COVID. Their rotations with residents tended to be at newer/disorgannized programs where they frequently skipped multiple days in a row or were dismissed a few hours in on other days. The ones shooting for better programs went out of their ways to secure better quality rotations but many took the easy way out. M1s at my school essentially have more clinical experience and know how to use an EMR better than those OMS3/4s especially during COVID

 

[calivianya]

I am pretty sure it's now a accreditation requirement that at least one rotation in third year is with a residency program or with residents? How did people go with doing all outpatient for the entire year?

I can only speak to what my friend's told me but their schools essentially looked the other way especially during COVID. Their rotations with residents tended to be at newer/disorgannized programs where they frequently skipped multiple days in a row or were dismissed a few hours in on other days. The ones shooting for better programs went out of their ways to secure better quality rotations but many took the easy way out. M1s at my school essentially have more clinical experience and know how to use an EMR better than those OMS3/4s especially during COVID

This. All of this.

I don’t think the hospitals my school is associated with have many new residency programs… otherwise I’d say your friend goes to my school.

All the local hospitals near my school kicked med students out (yet another perk of the schools/institutions not directly owning the hospital or vice versa) and my school made no effort to find rotations with residency programs for these students. Many essentially shadowed in outpatient clinics for all of third year. I was very unhappy about my site placement initially but I turned out to be very lucky - I am at a remote site nowhere near my school, and they did not kick us out, so every rotation I had was at least partially if not fully inpatient. It puts me in an extreme minority for my class… but I also only had one rotation with a residency program. All of my other rotations were preceptor based, but the fact that they were inpatient and had me writing notes, rounding, and presenting on every rotation was helpful.

 

[BorntobeDO?]

I’m not sure swaps are any better.

I am at a school that has a lottery and allows swaps. Naturally, lots of money exchanged hands. You wonder what happened when you watched lower SES students be excited about their site then mysteriously have a different site… until you hear the rich kids talk about paying five figures for a new rotation site. $20k was the high score I heard in my year, directly from the person who paid the $20k. I don’t blame the poorer kids, it’s hard to resist $20k in cash when you’re living on a student budget.

As someone who is living off student loans, though, I couldn’t buy a better rotation site off of anyone. Being completely real, since I got the site that most people rank dead last, I’m sure it would have been way more than $20k to get rid of my site if anyone was even willing to swap at any price point at all. I can’t help but be of the opinion that more things that allow rich people to take a dump all over everyone that didn’t grow up wealthy isn’t all that great.

I mean, if someone paid me 20k for my site, that would be a good deal.