Norcalguy's Residency Application Process

Pre-Med & Medical School Pre-Med Topics
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<p>^ Yes it depends on the field of medicine that you go into, not the place where you did residency. For example, lets say you are really interested in becoming an ophthalmologist/neurologist/dermatologist. You can’t see yourself doing anything else. Then will it really matter that you dominated the sats, the mcats, step 1, etc, etc? No it won’t. </p>

<p>Similarly a family friend graduated from MIT undergrad, went to Harvard Med, did her residency at BCM in order to become a pediatrician. She could have taken the easy route and still make the same amount of money, but she decided to go the most prestigious route possible to become a pediatrician…Was it worth all the extra dough for those top schools not to mention all the extra amount of competition? In the long run, no. :(</p>

<p>For Law, and Business, the prestige of your grad school can take you a long way in terms of career prospects. Just look at the average starting salaries of kids at top 10 law schools vs. starting salaries at law schools ranked 30-40. The same goes for MBA programs. In today’s law market, a lawyer for my parents told me that if you graduated from a top 10 law school you should be able to find a job, but if you didn’t good luck. As a result, in law and business there is A LOT more incentive to work your ass off to get into a top grad program. Not as much in medicine.</p>

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<p>Colleges00701:</p>

<p>While pedigree doesn’t matter for private practice, it does make a difference if you’re interested in academic medicine. If you want to be the chairman of the department, you’ll need some impressive institutions on your resume.</p>

<p>I guess I should also say that if you want to be a doctor to Hollywood stars, then pedigree also matters, but I hope no one here is going into celebrity medicine. :)</p>

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<p>^^^ Lol, I agree. I should have been more specific and said “practicing doctors”. Also who wants to work for high maintenance Hollywood patients? :)</p>

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<p>I know nothing about peds residency so I don’t know if BCM is a good program or not. But, in my opinion, it’s worth it to work hard to have a good med school record if it gets you a good residency in the location you want. Residencies differ quite widely in terms of quality (who you get to learn from, your caseload, the breadth of cases, the amount of research available, etc.). Where you train and how you train really does impact the kind of physician you will be for the rest of your life. Perhaps even more importantly to some med students is location. Most physicians practice near where they complete residency. If you want to do residency in CA or Chicago or NY, you need to have high stats because those are desirable locations. So, having high stats and good LOR’s isn’t just for getting into plastics or derm. The best peds or internal medicine residencies are quite competitive.</p>

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<p>^One of the best peds in a country (consistently #3) is Cinci Col. of Med. It would not be considered presitgious enough by person who went to Harvard. Isn’t it ironic though?</p>

126

<p>radiology sucks now. they are outsourcing and the pay is going wayy down. have fun wit that one…</p>

127

<p>They’re going to need mighty long catheters if they’re going to be doing those IR procedures from India ;)</p>

128

<p>NCG</p>

<p>Congrats on the Honors sub-I rotation. Somehow I missed your post announcing it.</p>

129

<p>Regarding the outsourcing, by law you are required to have a US licensed radiologist in practice. If any images are read in India or China, a US licensed radiologist has to get these data, confirm diagnosis, and interact with patients.</p>

130

<p>^For now. </p>

<p>I’m not sure if final reads will ever be done by foreign trained radiologists. I think there’s too much of a liability issue in having to hunt down someone halfway across the world for missing something on imaging. The other thing is the communication aspect of the process. There’s a misconception that radiologist don’t need communication skills. I argue that radiologists need perhaps more communication skills than an average doctor. Every day, we communicate with physicians and patients alike (during interventional procedures). The phone in the radiology room is constantly ringing because we have to communicate findings with the physician that ordered the imaging. Sometimes, the physician will bring his entire team to the reading room to look at the films with us. I think all of us have had less than satisfactory results when calling customer service in India and I just don’t think it’s going to have much better with foreign radiologists reading our films.</p>

<p>The bigger threat to diagnostic radiology may be clinicians reading their own films. I’ve already worked with a couple of clinicians who own their own x-ray and CT machines, order, and read the films themselves, bypassing radiologists altogether. The problem is that they only focus on their area of specialty. I worked with an ENT who specializes in sinus issues. He has a CT machine for which he can order a head CT of the sinuses. He then looks for signs of chronic sinusitis on the film. The problem is, what if the patient incidentally had a mass in the orbits or the neck that was missed on the CT? If you read your own films, you have to take all the liability for anything that is missed. A CT of the sinuses contains more than just the sinuses. It contains head structures, vessels, facial bones, etc. A radiologist is trained to detect any abnormality that’s in any of those structures. Someone who can only look for mucosal thickening in the sinuses will inevitably miss a cancer or infection that’s in the area.</p>

<p>There’s a reason radiology residency is 5 years long. There’s a lot of subtitles in reading films that require dedicated training.</p>

131

<p>And keep in mind, it’s not just radiologists that face territory wars. For example, it might surprise some people that most neurosurgeons in private practice do exclusively spine surgery rather than brain surgery. This is because “low back pain” is big business. This is the same stuff that orthopedic surgeons treat. Notice that Petyon Manning got his neck surgery done by a neurosurgeon at Northwestern, not an orthopedic surgeon.</p>

<p>Another example, is the territorial war between CRNA and anesthesiologists. This has become so bitter that some anesthesiologists are refusing to train CRNA’s. To their credit, the CRNA’s have spent a ton of money lobbying and conducting (flawed) studies that show they have equivalent outcomes as the more expensive anesthesiologists.</p>

<p>And the battle between interventional radiologists, vascular surgeons, and cardiologists have been raging for years now. Today, echos and angioplasty and stenting of coronary arteries are done almost exclusively by cardiologists. Vascular surgeons treat mainly arterial diseases while IR treat venous problems. Despite the number of techniques that have been stolen by other specialties, IR stays on top because it continually reinvents itself and develops new procedures.</p>

<p>Surgeons are far from immune to all of the competition. With pressure from specialties that can do non-invasive procedures, surgeons have had to develop surgeries that place the patients at less risk (robotic surgeries, laproscopic surgeries). In addition, they’ve had to do research showing surgical techniques are superior to these less invasive procedures. For example, CABG (performed by cardiothoracic surgeon) vs. angioplasty and stenting done by cardiologists. Or clipping of an intracerebral aneurysm by neurosurgeons vs. coiling of the aneurysm by interventional neuroradiologists. Stenting of carotid arteries vs. doing a carotid endarectomy. </p>

<p>Even primary care specialties that don’t seem lucrative face encroachment by nurse practitioners and PA’s. Who treats sore throat these days? Your primary care physician or the NP at the local Walgreens?</p>

<p>That’s the beauty and the curse of medicine. You are constantly trying to make yourself better and learning new things. But, if you don’t, you will quickly become obsolete. That’s why I say you gotta love competition if you want to become a physician. You will always face competition from other physicians and from people with less training. You are constantly having to prove that you’re worth the big salary you’ve worked so hard to earn. MiamiDAP loves to talk about job security in medicine. It’s worthless to have a job as a physician if you have no patients. You are constantly fighting to keep your patients and to keep yourself in business.</p>

132

<p>^ Fantastic post</p>

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<p>My uncle does something like that. he is a neurologist but has his own MRI machine, CT machine. Although he does work with radiologists for a lot of things, he says it much more lucrative for a neurologist to have his own MRI and CT machine, because then he can make money from billing his neurology patients and he can bill any of his neurology patients that need CT scans or MRI scans (instead of them going elsewhere to get those services and cutting him out of some serious MRI $$$$). I don’t know if he reads all/most of his own scans but he does work with a radiologist sometimes so I am guessing he reads most of his own scans.</p>

134

<p>I also want to say that ncg’s post above is fantastic.</p>

135

<p>Lots of interesting things in this thread since I last checked in.</p>

<p>1) Studying for step one is awful, particularly looking back at how little of that information is actually useful in clinical practice. I don’t know what the data says, but in my personal experience, there’s not necessarily much correlation between presumed Step 1 scores and the scores I give on evals (I can guess where students scored based on their career aspirations). As far as how actual grades end up, it really depends on the clerkship and how much weight is put upon Shelf exams, evals, and what ever other projects or components are graded (oral exams, simulated patients, presentations, etc). </p>

<p>2) The prestige of a residency program, and the quality of the clinician it produces are two very different things. I feel like this is particularly true for peds and internal medicine, where the gap between being a generalist and a specialist is significant. Going to a prestigious location is helpful (though variable in actual utility) if you’re going into fellowship. However, being prestigious within the particular specialty you’re pursuing for fellowship is even more important (eg, my residency program is pretty good overall, but I’m reaping the benefits of the excellent Peds Critical Care staff as I apply for fellowship). Prestige is much more difficult to relate to though for the general pediatrician/internist.</p>

<p>Culture is important for everyone though when it comes to clinical acumen. I have friends who are in one pediatric residency at a place considered a bit more prestigious than my residency program. It just so happens that I know a critical care fellow there from my residency. Every one says the same things - clinically, my program produces stronger, more capable residents. What’s the difference? At my program, the residents have far more responsibility, and make more decisions on sicker patients. At this other program, many patients are admitted by their private pediatricians, who the residents then call and ask what the private pediatrician wants done. At my hospital, private pediatricians have limited privileges, so the academic hospital general pediatricians and residents manage the patients with almost no outside involvement, which means the residents get more responsibility. Another example based on the stories from one of my friends who is a critical care fellow at another prestigious hospital on one of the coasts - any patient at that hospital who requires more than 2 liters per minute of oxygen (not that much, even for a neonate) is required to be managed by the critical care service. So the residents get no experience in managing patients who need increased levels of support, except for their months on the PICU services (usually just 2 months out of the 36 month residency). Meanwhile at my hospital, I frequently manage patients on up to 8 liters per minute, and don’t move them to a higher level of care or notify the critical care team unless they’re still in significant distress on that higher level of support. In the end, for me as a future intensivist, that means a minimal amount, but for my friends who are going to be general pediatricians? Which group of graduated residents do you want taking care of your child when they get admitted to the local hospital for RSV bronchiolitis? The ones who have managed lots of those types of kids, even when they get pretty sick, or the ones who, at the first sign of distress, handed off to the specialists?</p>

<p>3) Territory wars are all over the place, but at the same time, there’s becoming more and more fragmentation of medical fields all the time. Adult cardiology is already split into electrophysiology, and interventional sub-sub-specialists, and there are a growing number of programs offering extra training in heart failure. Pediatric cardiology hasn’t formalized their extra training programs yet, but I think soon, there will be formal interventional cards and critical care cards programs as well as transitional programs for taking care of adults with congenital heart disease. Pulmonology in the adult world is creating interventional pulmonology fellowships. In the pediatric critical care world, a number of the programs I’m looking into are putting new focus on neurocritical care. So in one sense, groups are expanding their role, while at the same time trying to put a fence up around aspects within their own specialty.</p>

<p>4) An update on my application process…
Unlike for NCG and his leisurely pace, with the match day for fellowship applicants being the last day of November, July was a sprint for me. As it stands, all my materials have been sent in, with 2 LoR’s awaiting to clear the central clearinghouse and get uploaded (this part is the most frustrating because it wasn’t an issue during med school when everything went to the Dean’s Office). I thought initially that I wouldn’t get any interview invitations until everything was available to the programs, but in the last two weeks, I’ve received invites from 5 of the 10 programs I applied to. I’ve set up interviews at 4, booked flights for 2, and am awaiting word from the 5th if my requested dates will work. As it turns out, one of the programs, I already know I’m going to cancel on, and I’m trying to figure out which of the remaining 5 I’ll probably pass on if I get invited. The trouble is that of the remaining 5 locations, one is my home program (have to interview here), one is a location that I absolutely loved when I interviewed for residency, a third is probably my most desired city location if not most desired program (which it might be), and the other two are really quality programs including one that has a graduate of my residency as a current fellow right now. It’s time consuming and expensive to do all of this, but we’ll see what happens…It’s also incredibly exciting and I’m really ready to explore what these programs have to offer.</p>

136

<p>There are so many factors that go into the residency selection process and for once prestige is probably not the most important. I think location has vaulted to become the #1 factor for most people. This is the time when you seriously need to think about where you want to live for the next 10 years. </p>

<p>And even when judging the quality of a program, prestige is just one of the many factors (including how malignant the program is, how happy the residents are, the depth and breadth of the cases you’ll see, etc.). Speaking with one of the residents the other day (who interviewed at some very impressive programs), she gave me her list of programs she liked and didn’t like. When I asked for her criteria, she shrugged and said “gut feeling.” Despite how scientific we pride ourselves on being, in the end, sometimes it simply comes down to a gut feeling of you think you will get the best training and where you think you will be the happiest.</p>

137

<p>

Sorry about being off the topic: Is it likely that this is also applicable to the selection of the medical school to matriculate, with the exception that the location factor is not that important?</p>

<p>I observe that, for applicants who are lucky enough to have a choice of schools to attend at the end of the medical school application cycle, it appears that many care about 1) how good (e.g., “not borderline abusive” or the school tends to be protective of their MS3 students) is the clinical year training 2) whether there are grades for pre-clinical years 3) how easy to get into the school (“prestigious whore” factor :)) 4) how much debt at the end of 4 years.</p>

138

<p>It would be nice if people picked med schools that way. However, I think many applicants are still guided by the trio of prestige, money, and location. For one thing, the training just isn’t that much different between medical schools. And, two, there’s the US News, a widely publicized ranking that makes it clear who is above whom in the totem pole of med schools. This doesn’t mean that the student will automatically choose a med school ranked #18 over one ranked #23. But, this does mean that it’s unlikely someone will pick Boston University over UCLA or Penn. As for med schools not being abusive to its med students, I don’t even know what that means. On surgery, some of my classmates barely did any work. I worked over 80 hours per week (even though I was told not to) because I needed a recommendation letter. It’s much more dependent on the individual med student what they get out of 3rd year.</p>

<p>Residency programs differ MUCH more widely over the factors you talked about: quality of education, caseload, how hard residents work, etc. Some programs make radiology residents work on the weekends. Some programs don’t. Some programs have q3 call. Some have q5 call. Some have overnight call. Some have night float teams. Some programs allow you to moonlight and make an extra $500 a week. Some programs don’t. Some programs have genuinely unhappy residents (like all of them) and some programs have happy residents. These factors make a HUGE HUGE difference in how your life will be over the next few years. At some community programs, you may only diagnose one brain tumor a month. At my hospital, every week, we have an interdisciplinary conference with neurosurgeons, radiologists, and pathologists where I see 20 cases of brain tumors, all patients at our hospital. At a busy ER in a level 1 trauma center, you may diagnose multiple skull fx, hematomas, subarachnoid hemorrhages in one night. At a community hospital, you may read 3 negative head CT’s a night for “headache” or because some teenager fell out of bed. So, I think the discrepancies between residency programs are much greater than between medical schools. </p>

<p>The other thing is that it’s far more difficult to find out exactly which residency programs are more prestigious than which other programs. On auntminne (which is a radiology forum), there are still a few people willing to rank exactly which radiology programs THEY THINK are #1 and which are #2, 3, 4, and so on. But, there’s no definitive ranking out there. And with people having to apply to 40 programs and matching into just 1, without a choice, there is far less focus on splitting hairs between Mass General and University of Indiana (which is a great radiology program). Someone with ties in the Midwest will probably rank University of Indiana over Mass Gen.</p>

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<p>NCG</p>

<p>Posts 136 and 138 are excellent and really hit the nail squarely on the head. Good job!</p>

140

<p>Is “Kingsbrook Jewish Medical Center in Brooklyn” regarded as a relatively “lower-ranked” residency program by most applicants? Will the medical school students with a higher qualification (say, top 50% of his medical school class from a top 50 medical school) likely choose not to go there?</p>

<p>I knew nothing about any residency programs but I learned about that particular residency program from the following link due to an unfortunate event:</p>

<p>[Doctor</a> at Yale Medical School Is Shot to Death - NYTimes.com](<a href=“http://www.nytimes.com/2010/04/27/nyregion/27haven.html]Doctor”>Doctor at Yale Medical School Is Shot to Death - The New York Times)</p>

<p>NYC seems to be a very attractive location though.</p>

<p>(BTW, I really could not understand why a 44 yo, the murderer in this case, who did not grow up here in US would want to choose this career path at such a old age, just because his science/academic background is good enough. I think he failed to understand that practicing medicine requires more skills than just the science/academics skills. For example, I remember that BDM once said the public speaking skill may be one of the most important skills which determines whether you will be successful after 1.5-2 pre-clinical years.)</p>