Which program should I rank higher?

[tcon91]

Hey everyone, I need help deciding between two FM programs I could see myself training at. Each has its pros and cons. After residency, I would really love to have my own private practice if possible but would most likely work as a hospitalist at either of these non profit hospitals and shoot for PSLF to get rid of high student debt burden. Which program would you rank number 1 and why?

Program A:
Pros:

• I have connections here. I have no doubt about matching
• Residents and faculty are very friendly and I felt like I fit in here
• I live a mile away from the hospital
• Many people go into this program for the better lifestyle. 4 weeks vacation that you can arrange this any way you like, even take it all at once
• No 24 hrs or nights during inpatient medicine blocks just 12 hr shifts
• In patient medicine population is diverse. Old, young, minorities, affluent etc
• Peds and ob rotation are done at same hospital
• Out patient clinic training is solid. Clinic is in an under served area and patients are very complex. Good amount of pathology.
• Residents get their own panel of patients in clinic and have a lot of autonomy. They learn how to bill.
• Residents see high volume of patients in clinic and have no trouble meeting numbers
• Pay is above average

Cons:

• Despite faculty being very nice, attendings don't really teach here.
• Administration isn’t proactive about making changes or trying to improve program
• I live one mile away from hospital so I will see friends and family members at the hospital at some point guaranteed.
• In patient medicine training is perhaps weak? Again no one really teaches except for 1 or 2 IM hospitalists that are very knowledgeable.

Program B
Pros:

• This is a program that’s part of a major health institute with many resources.
• Residents and faculty are very friendly.
• Administration actively makes changes according to resident feedback
• All the attendings love to teach ***
• Program is big on wellness for residents/employees and people are very happy to be here. Many residents graduate and come back to work at this program as hospitalists.
• Residents are encouraged to pursue their goals. The hospital has many tracks available for those interested in hospitalist, urgent care, sports med, various fellowships etc.
• Hospital is 30 min away from home.
• Resident pay is one of the highest in the country

Cons:

• The major con with this program is the outpatient clinic which is done at the PD’s private practice in an affluent area. Most of the patients that come in are just looking for refills or preemployment physicals.
• Residents don’t get their own panel of patients in clinic and have very little autonomy. They don’t learn how to bill.
• Some residents have trouble meeting their continuity numbers.
• In patient medicine is primarily geriatrics. Average age of census is 90 years old.
• Peds and OB are done at different hospitals that are 1 hr away from home.

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[AMEHigh]

Definitely program A. I don’t think you can genuinely have a good residency experience as an FM with a poor outpatient experience and a mediocre inpatient experience.

 

[tcon91]

Definitely program A. I don’t think you can genuinely have a good residency experience as an FM with a poor outpatient experience and a mediocre inpatient experience.

Thanks for the advice!

 

[MedicineZ0Z]

Is there, an option C? Sounds like neither provide good inpatient training. No nights should be a deal breaker as well as crazy as that sounds.
If you want to be a hospitalist then you need very good inpatient training and at least a couple months of good ICU experience.

 

[tcon91]

Agree that A seems less than ideal if your goal is to be a hospitalist. Qualities of strong inpatient training would be: about 1/3 of your time over your 3 years in inpatient medicine, either open ICU or 2+ months ICU rotations available, running codes/rapids/etc, lots of specialty care available so you don't have to transfer as much stuff out, lots of faculty and alums doing hospitalist work. Agree that you gotta have some night shifts in there. Clinic experience for A seems good though. I disagree with the above post that attendings don't matter. Yeah, you can get the hard science/knowledge from other sources, but a lot of being a good doctor is getting that clinical spidey sense that you can't get from an uptodate search. My program has outstanding attendings and honestly they are far and away the best learning resource I have, and it's a huge asset to be able to learn from their years of experience and unique ways of doing things. You may also miss out on learning some of the business side of medicine and just like how to be a good leader on the healthcare team without good mentorship from attendings.

B's clinic experience seems pretty crappy...it has been REALLY valuable to me even in the first 6 months of intern year to truly have my own patients. Lots of great learning. If they have lots of grads who are hospitalists you can probably count on that training being strong. Tracks sound great, especially that there's a hospitalist track if that's truly your interest. I don't think that having an older inpatient census is necessarily a bad thing (though it certainly would be in the outpatient setting). Most of the problems old folks get that warrant hospitalization are going to happen in young people too and not be managed any differently. If you can handle an old dude with multiple comorbidities and a grocery bag full of medications you can handle a 30 yo with pyelo or asthma exacerbation. Sucks that peds and OB are not close by, but if the training is good and that's valuable to you may be worth it.

Honestly these programs sound super different. Are there any happy mediums with regards to the balance between inpatient and outpatient training? Sounds like you could benefit from reflecting a little more on what you actually want out of your career before making your rank list. Good luck!

I agree. Really the main differences are Program A with great outpatient training or Program B with good in patient training and excellent teachers. I've rotated at both places and I did enjoy both programs. I do believe having great teachers makes a big difference. Program B's out patient experience was pretty disappointing and that's really my only hangup about them.

Being a hospitalist is really a means to an end. Hopefully I'd benefit from PSLF down the line and could also use the weeks off to either moonlight or come up with plan for solo practice.

Decisions, decisions.

These 2 programs are really the best of what I got. I am a DO student with competitive application but due to geographic constraints (wife wants to be near family) I'm stuck between these two. Thanks for your advice!

 

[hallowmann]

Damn, those options are rough. Neither are ideal. I would choose A if stuck between those two though. No program is going to be perfect, but it sounds like you'll at least get good FM outpatient training at the first. You can always do a 1yr fellowship if you want better inpatient exposure, but I'm not sure how you could fix poor outpatient training in an FM residency.

I'm going to address the cons here individually in bold.

The cons for A:

• Despite faculty being very nice, attendings don't really teach here. - That sucks, but to be honest, a lot of education is by experience in residency. You learn by virtue of having patients with pathology and learning treatment guidelines, how they improve, how they get worse, etc. because you have to treat them, YOU are their doctor. Its nice to have people that are big on teaching, and the experience is nice, but I think its something more salvageable if you have a lot of pathology.
• Administration isn’t proactive about making changes or trying to improve program - This can be rough. This is a tough one to find the silver lining in. It might affect your happiness, but likely won't hurt your training.
• I live one mile away from hospital so I will see friends and family members at the hospital at some point guaranteed. - It doesn't matter. This is going to happen no matter where you are. You are going to bump into patients you know at some point.
• In patient medicine training is perhaps weak? Again no one really teaches except for 1 or 2 IM hospitalists that are very knowledgeable. - That sucks, but if the pathology is good, then again you can salvage it like the first con.

The cons for B:

• The major con with this program is the outpatient clinic which is done at the PD’s private practice in an affluent area. Most of the patients that come in are just looking for refills or preemployment physicals. - This is terrible. You need good outpatient training in FM. You need to see a variety of pathology. FM is so broad, and you need to have a good sense of what is manageable in an FM office and what isn't. A lot of what you will see in practice is people there for physicals or refills, but that shouldn't be all you see or even the majority.
• Residents don’t get their own panel of patients in clinic and have very little autonomy. They don’t learn how to bill. - This clinic experience just sounds terrible. The whole point of FM is that you have continuity and you are following patients through not just a disease process, but also through their lives as they develop things completely out of the blue. Without that, what's the point.
• Some residents have trouble meeting their continuity numbers. - This just points to how bad it all is.
• In patient medicine is primarily geriatrics. Average age of census is 90 years old. - Inpatient medicine is primarily geriatrics, because they are often the most sick necessitating admission to a hospital, but the average age being 90 is insane. I'd be worried about pathology at that point, and without good pathology I don't know how you can call the inpatient training good.
• Peds and OB are done at different hospitals that are 1 hr away from home. - Not really an issue. You have to commute. It'll suck during those rotations, but beyond that, what does it matter. What's much more important is whether this is good Peds/OB training.

 

[MedicineZ0Z]

Damn, those options are rough. Neither are ideal. I would choose A if stuck between those two though. No program is going to be perfect, but it sounds like you'll at least get good FM outpatient training at the first. You can always do a 1yr fellowship if you want better inpatient exposure, but I'm not sure how you could fix poor outpatient training in an FM residency.

I'm going to address the cons here individually in bold.

The cons for A:

• Despite faculty being very nice, attendings don't really teach here. - That sucks, but to be honest, a lot of education is by experience in residency. You learn by virtue of having patients with pathology and learning treatment guidelines, how they improve, how they get worse, etc. because you have to treat them, YOU are their doctor. Its nice to have people that are big on teaching, and the experience is nice, but I think its something more salvageable if you have a lot of pathology.
• Administration isn’t proactive about making changes or trying to improve program - This can be rough. This is a tough one to find the silver lining in. It might affect your happiness, but likely won't hurt your training.
• I live one mile away from hospital so I will see friends and family members at the hospital at some point guaranteed. - It doesn't matter. This is going to happen no matter where you are. You are going to bump into patients you know at some point.
• In patient medicine training is perhaps weak? Again no one really teaches except for 1 or 2 IM hospitalists that are very knowledgeable. - That sucks, but if the pathology is good, then again you can salvage it like the first con.

The cons for B:

• The major con with this program is the outpatient clinic which is done at the PD’s private practice in an affluent area. Most of the patients that come in are just looking for refills or preemployment physicals. - This is terrible. You need good outpatient training in FM. You need to see a variety of pathology. FM is so broad, and you need to have a good sense of what is manageable in an FM office and what isn't. A lot of what you will see in practice is people there for physicals or refills, but that shouldn't be all you see or even the majority.
• Residents don’t get their own panel of patients in clinic and have very little autonomy. They don’t learn how to bill. - This clinic experience just sounds terrible. The whole point of FM is that you have continuity and you are following patients through not just a disease process, but also through their lives as they develop things completely out of the blue. Without that, what's the point.
• Some residents have trouble meeting their continuity numbers. - This just points to how bad it all is.
• In patient medicine is primarily geriatrics. Average age of census is 90 years old. - Inpatient medicine is primarily geriatrics, because they are often the most sick necessitating admission to a hospital, but the average age being 90 is insane. I'd be worried about pathology at that point, and without good pathology I don't know how you can call the inpatient training good.
• Peds and OB are done at different hospitals that are 1 hr away from home. - Not really an issue. You have to commute. It'll suck during those rotations, but beyond that, what does it matter. What's much more important is whether this is good Peds/OB training.

Yeah to second this, not sure how the inpatient training will be good if your average age is 90. There's loads of unique pathology I saw in my very first week of FM inpatient in patients who were under 40 years old.

 

[Splenda88]

Option A look better on paper than Option B