Are community trained residents better?

[europeman]

I'm at an academic, big named institution.

I wouldn't really trust any of the chiefs graduating now to really be comfortable surgeons right now working on their own. Maybe after a year of attending experience... Maybe after fellowship, etc.

But the extent of autonomy we are given is lap appys, perirectal abscess, and the occasional small open case (open g tube, closure/washout, etc)

Don't get me wrong. I love my program. And we are well trained in the sense that we are exposed to variety of high end surgery and a significant amount of laparoscopy (80% of our colons are lap.... We do. Lot of foregut lap stuff).

Most attendings give us a lot of room to do the case as chiefs for the laparoscopic stuff. Open stuff not so much (I mean it's you and the attending... As usual... Never u and another resident).

Then the specialties like vascular are horrible. Fellows steal everything.... Or u r forced to double scrubs. The community residents have no fellows to compete with. So while technically they get go scrub on less cases maybe, their experience is stronger.

I trained to be a surgeon first and foremost... So I'm surprised I feel less prepared than a resident from a community program.

Your thoughts?

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[SLUser11]

Your thoughts?

My short answer is no. I don't believe community trained residents are inherently better, as your thread topic implies. Better looking, perhaps....but not better surgeons.

My long answer is that you can't really make blanket statements that separate community from university programs. There's too much heterogeneity, and programs with these different labels exist on all areas of the curve.

I believe that I personally received phenomenal training during residency, but I wouldn't conclude from this that all community programs offer phenomenal training.

The anxiety and insecurity that you are experiencing are completely normal from a senior resident or graduating chief. You have knowledge and experience, but over time you've become Socratic, and you are painfully aware of all of your knowledge and experience gaps....i.e. you know what you don't know. All graduating chiefs should have this...I'd be more scared than impressed by a chief resident who wasn't a little afraid of independent practice.

You'll be fine.

 

[Fah-Q]

The age old question: Watch it versus do it?

Is it better to have watched 20 Whipples or to have done 3? What if the surgeon you watched is the greatest pancreatic surgeon in the world and the surgeon supervising you do a Whipple is a hack?

In general, my opinion is quality trumps quantity. Learning sound decision making from good mentors is the most important aspect of surgical training. You will never know if you have that until you are well into your training program, unfortunately. The technical side comes with time and there is nothing unusual about being a so-so technician at the end of training. Getting into and out of deep **** on your own is what makes you a better surgeon and that ability comes from learning from your mentors do the same in their practice.

Watch your attendings closely everyday. You'll spend most of your first years in practice wishing you had paid more attention.

 

[SLUser11]

The age old question: Watch it versus do it?

Is it better to have watched 20 Whipples or to have done 3? What if the surgeon you watched is the greatest pancreatic surgeon in the world and the surgeon supervising you do a Whipple is a hack?

I think both of those scenarios are sub-optimal. You can't learn everything by watching, no matter how many times your old-school attending tells you that you can. Since you are an attending, you know that one of the highest-yield portions of your training is being able to troubleshoot and get yourself out of trouble. Do you think this can be accomplished if the attending takes the case away at the first signs of a struggle?

I think I'm reading too deep into your post. Do you believe that university programs possess an inherently higher quality? Do you think community surgeons are more prone to being "hacks?" Do you think community programs lack good mentors?

 

[Fah-Q]

Since you are an attending, you know that one of the highest-yield portions of your training is being able to troubleshoot and get yourself out of trouble. Do you think this can be accomplished if the attending takes the case away at the first signs of a struggle?

No.

Do you believe that university programs possess an inherently higher quality?

No.

Do you think community surgeons are more prone to being "hacks?"

No.

Do you think community programs lack good mentors?

No.

I think I'm reading too deep into your post.

Yes.

 

[dpmd]

My short answer is no. I don't believe community trained residents are inherently better, as your thread topic implies. Better looking, perhaps....but not better surgeons.

Coming from a community program I have to agree with you about the looks

The most striking thing I and other residents noticed in the various outside rotations I did (lacking transplant, burn, peds, cardiothoracic, and real vascular at my home institution meant we needed to go elsewhere for the experience) was the difference in confidence level for technical skills. I make no claims of surgical excellence, but I felt fine doing simple things like chest tubes and central lines unsupervised before the end of intern year. Rotating with 2nd and third year residents who needed help or were still getting comfortable with doing stuff like this was a eye-opening experience. Does that mean that I am better than them, of course not. Perhaps they spent more time in didactics up to that point and thought my knowledge level was surprisingly lower than theirs. However, I feel that my confidence in these simple tasks led to confidence at more difficult tasks (slower than I desired of course, I hate not being good at something) and ultimately led me to be more confident at complex decision making. Had I trained at a place that emphasized watching and didactics first, I am sure I would be more timid. It wouldn't have suited my personality or learning style. I'm sure there are those out there who would have thrived in that sort of environment (the kind of people who can watch someone doing some dance moves, then go out on the dance floor and mimic them with style). But for me, the early and progressive autonomy has let me know that there are a variety of things that I will be able to perform safely and independently, while also understanding the kinds of things that I will plan to have help with. Plus, all the operative trauma I have been involved with has helped me not to panic in the face of supreme badness (including when I as the chief am taking a 2nd or 3rd year through a trauma ex lap that turns into a little more than we were expecting)

 

[ESU_MD]

You'll spend most of your first years in practice wishing you had paid more attention.

This is a very profound statement. I tried to carry out this idea, but it is difficult because in someways you dont know what you are looking for at the resident level. We all thought we knew what was important, how to do things, etc...

However, if there was a way to go back and watch after having been out for a year- I would learn alot more. It sounds dumb, but I watch alot of youtube videos now and you would be surprised what you can pick up

As far as community vs academic training- dont think you can really make stereotypes- every residents training is different, even within the same institution. Just remember the hot chick who the attendings would take through each case step-by-step vs the dude from the middle east with the accent who wasnt even allowed to close skin.

 

[SLUser11]

No.


No.


No.


No.


Yes.

Fair enough. I couldn't tell from your post if you were implying that the university setting had less hacks and more mentors than the community.

And ESU, I had to chuckle a little bit at your last sentence. I remember that phenomenon quite well from my med school days.

 

[45408]

As far as community vs academic training- dont think you can really make stereotypes- every residents training is different, even within the same institution. Just remember the hot chick who the attendings would take through each case step-by-step vs the dude from the middle east with the accent who wasnt even allowed to close skin.

Man, you are not kidding. One of my med school classmates was led through a kidney transplant as a third year med student with no resident around.

 

[Black Surgeon]

I'm at an academic, big named institution.

I wouldn't really trust any of the chiefs graduating now to really be comfortable surgeons right now working on their own. Maybe after a year of attending experience... Maybe after fellowship, etc.

But the extent of autonomy we are given is lap appys, perirectal abscess, and the occasional small open case (open g tube, closure/washout, etc)

Don't get me wrong. I love my program. And we are well trained in the sense that we are exposed to variety of high end surgery and a significant amount of laparoscopy (80% of our colons are lap.... We do. Lot of foregut lap stuff).

Most attendings give us a lot of room to do the case as chiefs for the laparoscopic stuff. Open stuff not so much (I mean it's you and the attending... As usual... Never u and another resident).

Then the specialties like vascular are horrible. Fellows steal everything.... Or u r forced to double scrubs. The community residents have no fellows to compete with. So while technically they get go scrub on less cases maybe, their experience is stronger.

I trained to be a surgeon first and foremost... So I'm surprised I feel less prepared than a resident from a community program.

Your thoughts?

I've seen community program chief residents taking newly minted attendings from power house academic programs through cases.

From a students point of view, I would probably still opt for an academic program, as they generally (with few exception) offer a better shot at competitive fellowships.

 

[dpmd]

Hmm, as a student I was allowed to do the approach for a distal radius fracture. At the time I thought it was because I gave a good answer to his first question upon entering the room-"tell me what you know" (my answer, was 1. the score to last nights football game involving my school-the first day I was kicked out of a room for not knowing the answer, 2. the fracture pattern the patient had, 3 the dorsal approach to this fracture starts with an incision here and ...detailing the entire approach). I may need to reconsider my hotness level.

It is so unfair, but I wonder how often that happens versus the other way (one of the old boy's club type not letting a female do as much).

 

[droliver]

I think it's hard to generalize as there's such a wide difference between individual University or community programs. I trained at a well known surgery program (Louisville) that provided such an incredible well rounded experience and worked in many different hospitals (9) and a mix of university and community surgeons. I was right at the tail end of the old work hour rules and the kind of autonomy we used to have at the University and VA hospitals has kind disappeared at many places. I can remember doing an esophagogastrectomy at the VA with my attending across town, which you just aren't going to see again in this era. I actually did 2 trauma spleenectomies during my plastic surgery fellowship years at Louisville, as I'd be in the ER at night doing something on plastics call and get dragged into covering an emergent surgery because they were tied up in multiple other rooms and these were all my former junior residents and attendings.

I work with some residents now in a good community surgery program (Baptist Medical Center in Birmingham,AL), but I think compared to what I did it's limited in a lot of ways in the intensity and breadth of exposure. (It was very common to do 4-6 months of Q2 call each year in house at the University covering trauma and what they now call emergency surgery, and you'd look like an extra on "The Walking Dead" when you were done with the service). The residents we work with now actually get really well trained in laparoscopy and contemporary scope of surgery, but it's kind of like a Disney-fied environment to what I felt like I went through (my predecessors probably said the same thing about my generation as well LOL). That being said, I think they come out much better prepared to go to work then the local large university program (UAB) which has the stereotypical weaknesses and strengths of a lot of University programs.

During training, I really enjoyed the transition back and forth between highly supervised busy rotations in private hospitals, the chaos of a trauma center where you're overwhelmed, and the slower VAMC system beurocracy.

 

[MsKrispyKreme]

Man, you are not kidding. One of my med school classmates was led through a kidney transplant as a third year med student with no resident around.

Wow! Now I'll have to stop bragging about the appy I was allowed to do as an MS3.

I think that type of experience has more to do with intelligence, reliability, and drive than having a pair of boobs. The old boy's network usually makes it more difficult not easier.

 

[filter07]

Wow! Now I'll have to stop bragging about the appy I was allowed to do as an MS3.

I think that type of experience has more to do with intelligence, reliability, and drive than having a pair of boobs. The old boy's network usually makes it more difficult not easier.

don't stop believin'

 

[45408]

don't stop believin'

choked on my Pepsi a little bit right there...

 

[MsKrispyKreme]

Sausage fest.

 

[Danbo1957]

Over time, I've seen that the best community programs (say, Baylor-Dallas) turn out better trained residents than the best academic centers. But, the better academic centers (say, UCLA) turn out better residents than the better community centers.

 

[JackShephard MD]

Over time, I've seen that the best community programs (say, Baylor-Dallas) turn out better trained residents than the best academic centers. But, the better academic centers (say, UCLA) turn out better residents than the better community centers.

How would one find a list of the best community programs?

 

[SocialistMD]

Over time, I've seen that the best community programs (say, Baylor-Dallas) turn out better trained residents than the best academic centers. But, the better academic centers (say, UCLA) turn out better residents than the better community centers.

I think it all depends on (a) the surgeon and (b) the ultimate practice environment. You practice in Austin, where the setup is much more private practice than academic. The surgeons who trained in academic environments will not adhere to the same "rules" as the community-trained surgeons because it wasn't the environment for which s/he was trained. Community residents are taught better how to play nice in the sandbox by their faculty because that is part of their faculty's practice. Those trained in an academic center can be more brazen because of the protection the academic envelope provides.

You, personally, can't comment on the technical skills of every surgeon in Austin, as you haven't scrubbed with each one, so to make such a statement with the implications of technical expertise (which was my understanding of the OP's intent) is overstepping a bit.

In the end, residency is what one makes of it. I'm a pretty strict logger of my cases in terms of what I consider to be doing >50% of a case. Below is my current case log, 5 days into my chief year. The rotations I will do this year include HPB, Endocrine Onc, Vascular, Colorectal, MIS and the VA. At the end of the day, I'd put my case diversity and scope against any program in the country and I'd say I can get myself and a resident through any case I've done. I may not be the nicest consultant (though I'm working on that), but I know I can operate and take care of any patient with a general surgery problem.

When deciding on a residency, one should really look one's self in the mirror and ask where s/he wants to practice. If it is in the community, go to a community program. If it is academics, go academic. The operative technique will be taught at both, but how to interact in each environment will be better taught. If you end up in the community, that interaction will be more important, because your business will be much more dependent on how you are perceived than on how good you are in the OR, as few people will graduate with an inability to take care of most patients (especially with the upcoming pay-per-performance movement), but your table will be empty if you are a total d!ck.

 

[naus]

because your business will be much more dependent on how you are perceived than on how good you are in the OR.

Eh. I'm increasingly feeling that the best and least stressful way to get through medical school and residency is to find the cushiest path possible around the mean physician salary (that way you're neither a target for CMS to cut nor let to fall behind even more). Aim for the mean. There's less and less incentive to bust ass being good at what you do.

Medicine is no longer a profession. We're just a service job. Smile.

 

[europeman]

Naus... Im a chief reside and not, granted, 10 years with attending experience... But I'll tell you I * love* the crazy privilege we have operating on people's bodies.

You seem jaded.
In short, I couldn't disagree with you more.


Before you dwell on the negatives..... Think about the enormous fortune u have being in the position you are in doing what you do



European

 

[SLUser11]

You, personally, can't comment on the technical skills of every surgeon in Austin, as you haven't scrubbed with each one, so to make such a statement with the implications of technical expertise (which was my understanding of the OP's intent) is overstepping a bit.

Danbo tends to do that....but I think his avatar is funny so I let it go. The truth is he's not a surgeon, and his opinions are based on third-hand knowledge and reputation/rumor. Here's an example. The truth is that non-surgeons really have no concept of a surgeon's technical skills, and the label of "good" usually occurs for other reasons...often it's the way the surgeon treats consultants, and I've encountered several surgeons over the years that were technically below-average but enjoyed the label of the "best surgeon in town" due to them being super-nice and available for the FPs.

I may not be the nicest consultant (though I'm working on that), but I know I can operate and take care of any patient with a general surgery problem..

You and I both know that this would need to change regardless of your future practice environment. One thing Danbo does know well is which surgeons should be hired and which should be fired, which is often based on how well they play with others in the sandbox.

Even if you end up in academics, where personality disorders are better tolerated, you would make yourself and everyone around you miserable with a bad attitude, and that is ultimately obstructive to patient care and resident education.

When deciding on a residency, one should really look one's self in the mirror and ask where s/he wants to practice. If it is in the community, go to a community program. If it is academics, go academic.

the problem is that most people don't know what they want, and the majority of surgeons in this country don't end up in an academic practice. Do fourth year medical students really have a good understanding of the difference between community and academic surgery? Most students have very little (if any) exposure to the community. They also have a very limited understanding of what academic surgery entails. Do they really have the tools to make the decision that you recommend?


On another note, I applaud you for sharing your case log. We should probably do that sort of thing more often, as it gives students a better understanding of case diversity (e.g. if you had 200 vascular cases, they would conclude that Wash U is drowning in dead legs and dialysis access).

 

[SocialistMD]

You and I both know that this would need to change regardless of your future practice environment. One thing Danbo does know well is which surgeons should be hired and which should be fired, which is often based on how well they play with others in the sandbox.

The truth is, I'm not that bad, but I'm sure I'm worse than my community-trained colleagues, and it is because it is a component of the education that isn't taught at academic institutions. I'm a relatively nice person, so I don't treat people poorly, but the reprimand for being crappy to the ED or the medicine services isn't anything worse than a slap on the wrist, because I'm not going to cost my attendings money by being that way. The same isn't true at a community program.

the problem is that most people don't know what they want, and the majority of surgeons in this country don't end up in an academic practice. Do fourth year medical students really have a good understanding of the difference between community and academic surgery? Most students have very little (if any) exposure to the community. They also have a very limited understanding of what academic surgery entails. Do they really have the tools to make the decision that you recommend?

I think a lot of them do, if they are just honest with themselves. Do they really love teaching or do they really want a lab? If not, they probably won't end up in academics. Most convince themselves they want to be academic surgeons because they have to be able to sell that on the interview trail, as they think that is what programs want to hear.

On another note, I applaud you for sharing your case log. We should probably do that sort of thing more often, as it gives students a better understanding of case diversity (e.g. if you had 200 vascular cases, they would conclude that Wash U is drowning in dead legs and dialysis access).

I have nothing to hide. I think I will graduate as a well-trained general surgeon with a nice breadth and depth of case exposure. I still think Wash U is a great place to train for general surgery and I'd do it again if I could get in.

 

[SLUser11]

I think a lot of them do, if they are just honest with themselves. Do they really love teaching or do they really want a lab? If not, they probably won't end up in academics. Most convince themselves they want to be academic surgeons because they have to be able to sell that on the interview trail, as they think that is what programs want to hear.

I don't think it's that cut and dry. I would opine that MS4s know very little about life as a practicing surgeon. They have extremely limited experience, and often can't see past the in-hospital work and residency life that they've encountered.

They know almost nothing of life after residency...and most of them don't even know if they will do a fellowship, the nature of which will certainly affect the academic vs. community question.

I agree that you are certainly well-trained. On a side note, I have a great deal of respect for the Wash U CRS team. I met the new guy from Vandy at the meeting and he seems great as well. Good luck with chief year, and props to St. Louis for dropping down to #3 on the list of "most dangerous cities in America." Take that, Detroit.

 

[SocialistMD]

I don't think it's that cut and dry. I would opine that MS4s know very little about life as a practicing surgeon. They have extremely limited experience, and often can't see past the in-hospital work and residency life that they've encountered.

Yes, but looking at my med school classmates and the residents who have graduated from my residency, I was only surprised by the career path (i.e. community or academic) of one of those surgeons. The rest were (to me) easily predictable based on what I mentioned above (namely, the desire to teach or the desire to have a lab). If I can see it as an outside observer, I would think the individual would know if s/he is honest in his/her self-evaluation.

 

[Danbo1957]

Danbo tends to do that....but I think his avatar is funny so I let it go. The truth is he's not a surgeon, and his opinions are based on third-hand knowledge and reputation/rumor.

One thing Danbo does know well is which surgeons should be hired and which should be fired, which is often based on how well they play with others in the sandbox.

Surgeons are worth more than their weight in gold.

I've seen a lot of surgeries. My brother is a neurosurgeon and my father was a general surgeon. So I would say what I might know is second-hand.

It's been a buyers market at our hospital for the last thirty years. So, we really choose who we want. I've seen almost no turnover, surgeons come here and stay-- from third shift trauma to heart transplant. Surgeons become part of the community in which they work; they become leaders on the medical staff; and they take part in the committees that hire for other departments.

We rarely hire from non-Texas programs. Like many other important Texas hospitals many of our best surgeons are academicly trained and come from UT-Southwestern and San Antonio. Surgeons from UTMB, Houston-Methodist, and UT-Houston tend to stay in the Houston area, sellers' market there. Baylor-Houston surgeons are a breed unto themselves who subspecialize, rarely seen outside of the Texas Medical Center facilities!

Many of our surgeons have told me, who trained in the above referenced programs, that they admire the technical skills of surgeons trained at Baylor-Dallas (a very oldschool community program).

 

[Fah-Q]

Eh. I'm increasingly feeling that the best and least stressful way to get through medical school and residency is to find the cushiest path possible around the mean physician salary (that way you're neither a target for CMS to cut nor let to fall behind even more). Aim for the mean. There's less and less incentive to bust ass being good at what you do.

Medicine is no longer a profession. We're just a service job. Smile.

Very true.

 

[balaguru]

Under what circumstances would a surgeon trained at one of the academic programs you listed ever have an opportunity to assess the technical skills of a surgeon trained at Baylor-Dallas. I can't see this happening very often.

Many of our surgeons have told me, who trained in the above referenced programs, that they admire the technical skills of surgeons trained at Baylor-Dallas (a very oldschool community program).

 

[ESU_MD]

I think this is true in the sense that Texas is one of the best states to practice medicine. Tort reform, low malpractice and the economy is strong. Not to mention excellent weather and the Texan pride.

 

[SLUser11]

Under what circumstances would a surgeon trained at one of the academic programs you listed ever have an opportunity to assess the technical skills of a surgeon trained at Baylor-Dallas. I can't see this happening very often.

I think it's probably relatively common. The big academic centers in Dallas and Houston have multiple fellowships, and I would speculate that Baylor-Dallas residents frequently land in these fellowship spots, especially since there are 9 graduates per year. A fellow's technical skills are witnessed by residents and attendings alike. Danbo already mentioned how region-loyal Texans tend to be.

Not to mention excellent weather and the Texan pride.

Excellent weather for some....others could not wait to return to the seasonal midwest.

 

[Jay Gatsby]

I think this is true in the sense that Texas is one of the best states to practice medicine. Tort reform, low malpractice and the economy is strong. Not to mention excellent weather and the Texan pride.

Don't forget the women, old sport.

 

[balaguru]

I think it's probably relatively common. The big academic centers in Dallas and Houston have multiple fellowships, and I would speculate that Baylor-Dallas residents frequently land in these fellowship spots, especially since there are 9 graduates per year. A fellow's technical skills are witnessed by residents and attendings alike. Danbo already mentioned how region-loyal Texans tend to be.



Excellent weather for some....others could not wait to return to the seasonal midwest.

I think these numbers are actually quite small. In the 6 clinical yrs I've been at UTSW I've only known of 1 Baylor grad who came here for fellowship and 3 UTSW grads who went to Baylor for fellowship. I classify these perceptions of technical prowess along with malignancy, old schoolness, etc. UTSW today is quite different from UTSW 6 yrs ago and I imagine the same might be true of alot of programs so even if somebody worked with a resident or attending from another program 10+ yrs ago I'd argue their opinion is likely no longer relevant.

Like anything other field, if you want to hire a technically gifted surgeon find one who loves their job.

BTW, I love to operate and will be looking for a job soon

 

[SLUser11]

I think these numbers are actually quite small. In the 6 clinical yrs I've been at UTSW I've only known of 1 Baylor grad who came here for fellowship and 3 UTSW grads who went to Baylor for fellowship. I classify these perceptions of technical prowess along with malignancy, old schoolness, etc. UTSW today is quite different from UTSW 6 yrs ago and I imagine the same might be true of alot of programs so even if somebody worked with a resident or attending from another program 10+ yrs ago I'd argue their opinion is likely no longer relevant.

Like anything other field, if you want to hire a technically gifted surgeon find one who loves their job.

BTW, I love to operate and will be looking for a job soon

The Texas Medical Center has a lot more fellowship spots than UTSW. I'm sure the Baylor grads go there as well. Also, the story was passed along second hand, so it's not like Danbo is saying there are multiple well-conducted RCTs that show Baylor grads have superior hands....he's just saying that's the reputation at his hospital. We both know reputation has very little to do with fact. Also, if that one Baylor grad was good, it would be enough to generate a good reputation.

I think you just sort of resent the possibility that Baylor grads are perceived as having better technical skills than UTSW grads. I wouldn't worry about it too much, really. In my short surgical career, I have witnessed the technical prowess of surgeons from many programs, big and small, and I believe there to be a great degree of variability that doesn't necessarily fit with the pedigree. Some of the best and worst hands I've witnessed trained in the same location.

 

[balaguru]

I think you just sort of resent the possibility that Baylor grads are perceived as having better technical skills than UTSW grads.

Not exactly. I can't control nor am I interested in changing perceptions but I have to speak up when people try to perpetuate those I believe to be unfounded.