As a resident at a midwest program that currently takes 2 residents a year I think I can respond. First we just went through the process this past fall and received the maximum 5 year accredidation. As far a training goes, I would put our experience up against any. We have more cases than the residents can cover. As an intern and 2 you are scrubbing with a staff, doing much of the case. No double scrubbing. We have every specialty covered except tumor (which is even true at university programs). Our didatctics are strong and are OITE scores have been near or at the top in the nation.

Lenox Hill takes 2 residents per year. Anyone here think those two get substandard training?

My program director mentioned at our residency fair that programs that have only 2 residents in training will most likely not be getting accreditation and will not be a good place to train and your experience as a Resident will be very limited.
Skeletal

this makes no sense. if anything, a program with less residents would potentially be a better place to train as long as they have the attendings to support the program. i'd rather be at a program with 2 residents, as opposed to a program with 6-8 per year, tripping over each other, running to the O.R. (finally, as 3rd year residents) to triple-scrub a "sweet case".

how would the experience be limited with 2 per year??

just wondering who your program director is, so i know in advance where not to apply.

i think your program director is trying to spread false information to unsuspecting medical students who are easily fooled.

I am a PGY4 at a community program with only two residents per year. I am coming up on logging my 1700 case (and I still have 1.5 years left!) The majority of those (90%) first assist with me doing the case. Second point: these are the fellowships that guys do out of our program (last 6-7 years) > Birmingham (sports) X2, Haborview (trauma), Harvard (sports & joints), Pitt (joints), OSU (sports), Jefferson (shoulder & elbow), AGH (sports). I could go on. The operative training is not matched anywhere in the country. Didactics are daily conferences with Journal club monthly. OITEs have been great since I have been here. In addition, I know folks at other small programs and they say the same things about their program. I will say that research is harder to do at small places (limited resources), but is doable! Lastly: we just got reviewed this past summer and received 5 years as well. And we got approved for a third resident which we are matching in a few weeks. We do not have the big name but certainly have the game. Email me if you would like: jfazalare@gmail.com.

Your program director is perpetuating a sentiment shared by many program directors at large, academic programs. Unfortunately, there is SOME truth to his statement, but let me explain. I heard the same thing from my program director (at a large academic program) seven and a half years ago. He said basically the same thing and told me I was "too competitive" to consider going to a "community program".

Training at most smaller programs is not limited. I trained at a program with a total of 10 residents (including interns) with 26 staff with every subspecialty represented except tumor. I finished with 2500+ cases as first assist and was doing total hips/knees as a PGY-3. I did very well on my in-traning and passed part one with flying colors. I am 18 months into private general practice and am thriving, as I am as busy as my partners. I am by no means a genius sp? (I'm not even sure how to spell genius) or God's gift to surgery. I am merely a product of a solid training program. I am also not the exception, but the norm from my program. That being said, the program I graduated from is currently in a fight for its life to stay accredited by the RRC. I spent the last two years of my training worrying about whether I would graduate from an accredited program. Why? The details are way too involved to get into on this forum. Of course, the RRC has its "reasons", but most close to the situation sum it up in one word: Politics.

I would BEG your program director or any other large program chairman to explain to me how my training was inferior, especially when compared to academic programs that have twice as many residents as staff. Residents are standing 2-3 deep and logging it as a "case" as they waterski for three hours, and still only end up with 1200-1500 cases by graduation.

I'm certainly not implying that all, or even most, academic programs are as described above. Most community program chaimen would admit that most big, academic programs provide quality training. Unfortunately, the converse is not true. Valid or not, there is a sentiment among many academic programs that the training at smaller, non-academic community programs is inferior, to the point that some in the academic circles would like to see them shut down. For evidence, all you need to do is look at Simon's editorial a few years back in the front of JAAOS about the "critical mass" of programs, and how smaller programs can't adequately train orthopods. It was blatently biased and opinionated, yet presented as a fact. Unfortunately, I do not think he is alone in his opinion.

In summary, your director's comments about the quality of training at smaller programs is ludicrous, but there is something to the fact that smaller programs may have a tougher time maintaining accredidation unless they are politically well connected. Most are in no danger of closing during your training, but of course, neither was mine. At the time I made my rank list, my program had most recently been granted the maximum accredidation. I had no reason to think they would be fighting to stay open halfway through my training. My best advice is to give the smaller programs a look, but make sure the ones you rank high have directors that are well connected. You will have enough to worry about as a resident. The LAST thing you need is to add in the fear that you may not graduate from an accredited program and may have to change programs (or, worst case spend another year in training). Believe me, I've been there.

Hey guys,

Thanks for all the comments. I will definitely do my research for the programs I will be applying to this fall. Keep the comments coming please. Thanks.

Skeletal 2009. Not a resident at your program but have a friend that is and am aware of the shaft your program has received. It is a quality program and hope it continues to fight.

You meant Earthdawg.

At least for now, it IS continuing the fight. Unfortunately, it has an uphill battle. The only hope is for those at other community programs to take interest into the details surrounding the attempt of the RRC to close the program. While other community programs may be safe for now, if they don't take an active interest in the RRC's attempt to shut down an otherwise quality program for unjustified reasons, they could find themselves in a similar situation in the future.

I interviewed at 3 programs this year that have 2 residents a year. They all seemed very stong and two fit the personality of a program I am looking for and I ranked them highly. They all seemed to be well trained and well taught.

I think that like most things in life, its difficult to generalize all situations. Not all large programs are terrific and not all small programs are horrible. Most are in between the extremes.

I have trained at two larger academic inistitutions in the south....more of workman's programs than gentlemans (first Tulane and now finishing my last year at UAB). Here are some of my thoughts....take them for what they're worth.

1. Trauma training -- most of us at large academic institutions take quite of bit of call. And we often perform many of these cases as primary surgeon (tabs, complex intra-articular fx's, mangled extremities, etc). Many who train at smaller programs may ask "When am I going to really have to know how to do that case". The answer is probably never....but learning how to think/tackle cases of complex nature prepares you for the lesser "bread and butter" cases. With that being said, its very taxing and time consuming to be in a program that expects so much from its residents on a daily basis....maybe an advantage to the smaller prgoram in the short run.

Variety -- Just becasue you log 1700 cases during a 2 year period doesn't mean much if 1000 of them are primary total knees. Its good to have diversity in training so that you can see how different surgeons think. Learning specific operations is a waste of time in the long run. Learn how to think and operate and then learn specific operations. This will allow you to adapt and improve

Fighting for cases....don't assume there's a shortage of work just because people train at large programs. When your the epicenter of a city/state....things seems to funnel your way in waves.

Again, just some thoughts on training in general. Go where you like the attendings and the type of training right for you

I think that like most things in life, its difficult to generalize all situations. Not all large programs are terrific and not all small programs are horrible. Most are in between the extremes.

not sure where this generalization came from.

With that being said, its very taxing and time consuming to be in a program that expects so much from its residents on a daily basis....maybe an advantage to the smaller prgoram in the short run.

i guess smaller programs expect less of their residents?? there are small programs out there where the 5th year residents basically have a private "clinic" practice, and manage ALL the operative cases in the underserved population--trauma, elective, etc., as well as operating with private physicians of their choice (subspecialists)
imagine 365 days worth of cases and chief call (every other night) for just 2 chief residents--i guess if that's not "hard core" enough for you, you can divide your residency up at two "bigtime" programs.

not to come off rude, but the thread is about programs with 2 residents per year, and i'm not convinced you have much insight about what its like to train at such a program.

loggjammin,
I obviously touched a nerve of a smaller program guy. My point was to give legitimacy to what we do at the larger program and expand on my unique experience (especially the level 1 trauma experience we get).

My entire post was actually directed torwards Earth Dawg

from Earthdawg
" I would BEG your program director or any other large program chairman to explain to me how my training was inferior, especially when compared to academic programs that have twice as many residents as staff. Residents are standing 2-3 deep and logging it as a "case" as they waterski for three hours, and still only end up with 1200-1500 cases by graduation."

Obviously logjammin you feel that I'm an elitist and you are "Hard core enough". I think my "expectation" comment was aimed at the frustration of dealing with constant unrelenting trauma. My assumption that level 1 centers do crappier cases on a more frequent bases than a smaller program is way off the mark in your book. If your community programs brings the pain on a consistent basis like CHairty/UAB/SOuthwest/SHock/etc....than I do apologize.


But your response to me was quite rude

logjammin
"i guess smaller programs expect less of their residents?? "

I think non-level one trauma centers do expect less of themselves....that's why they're not level one trauma centers.

loggjammin
"there are small programs out there where the 5th year residents basically have a private "clinic" practice, and manage ALL the operative cases in the underserved population--trauma, elective, etc., as well as operating with private physicians of their choice (subspecialists)
imagine 365 days worth of cases and chief call (every other night) for just 2 chief residents--i guess if that's not "hard core" enough for you, you can divide your residency up at two "bigtime" programs.


OOOOOHHHH...imagine a world where there are 365 days of cases and your VERY own clinic. And your q2 as Chief (operating everyone of those nights none the less -- sure buddy). I think you highlited the strength of your program....flexibility in cases and private practice scenarios.

As far as not having insight into the smaller program....I have never walked in your shoes. That's true. But people with small shoes certainly have feelings and rights too so I will not step on yours (feelings) anymore

TrickKnee out

loggjammin,
I obviously touched a nerve of a smaller program guy. My point was to give legitimacy to what we do at the larger program and expand on my unique experience (especially the level 1 trauma experience we get).

i'm not hurt by your post.

Obviously logjammin you feel that I'm an elitist and you are "Hard core enough". I think my "expectation" comment was aimed at the frustration of dealing with constant unrelenting trauma. My assumption that level 1 centers do crappier cases on a more frequent bases than a smaller program is way off the mark in your book. If your community programs brings the pain on a consistent basis like CHairty/UAB/SOuthwest/SHock/etc....than I do apologize.

no one forced you into that position, you put yourself there, so don't complain. many small programs do specific rotations at big level I trauma centers, for a concentrated trauma experience. and most community programs get a steady stream of level II trauma--not anywhere near what a level I center sees, but good bread and butter to reinforce the experience they get when they rotate at the level I center.

just think, you've done so much trauma, you don't even need to do a fellowship next year (i'm assuming you're a 5th year), you can just come back on staff as a traumatologist--enjoy that.

I think non-level one trauma centers do expect less of themselves....that's why they're not level one trauma centers.

trauma encompasses (or at least should encompass) only a small portion of orthopedic surgery as a whole. i can't help it that your program(s) have been centered around it.

As far as not having insight into the smaller program....I have never walked in your shoes. That's true. But people with small shoes certainly have feelings and rights too so I will not step on yours (feelings) anymore

TrickKnee out

HA, at least you have a sense of humor.

loggjammin

I think we just hugged

Now I'm REALLY feeling uncomfortable. Too much man love.


I really had no intention to kick off an academic vs community program war with my comments. I have nothing but the utmost respect for most academic programs. I don't pretend to think that the training at my program or even the best private program is any better than most academic programs, but it was very effective and has served me well with regards to my career goals. I was simply trying to answer the orginial post regarding whether bias against smaller (read private, community) programs from the academic world and the RRCactually exists. I simply do believe there is a bias in some academic circles against community programs. I certainly think it is unjustified, but it does exist. That is all. To any academic guy who is somehow threatened by this, I apologize. It in no way implies anything whatsoever about the quality of training at academic programs.

After going through the whole community vs academic argument several times in med school, then residency, and now in fellowship, I can say that the exact same statements were being made about 7 years ago when I was a MS3.
Its like the freakin middle east, neither side wants to admit the other has any merit and is unlikely to be settled. We should just "agree to disagree" b/c having a pissing match/dick waving/chest beating contest on an anonymous internet forum wont change peoples pre-concieved notions. Most people have a tendency to want to feel good about themselves, so they will say whatever situation they are in is, of course, the right/best way to train. People will brag about their strengths and downplay their weaknesses. Especially on an anonymous chat board.

Its like the freakin middle east, neither side wants to admit the other has any merit and is unlikely to be settled. We should just "agree to disagree" b/c having a pissing match/dick waving/chest beating contest on an anonymous internet forum wont change peoples pre-concieved notions. Most people have a tendency to want to feel good about themselves, so they will say whatever situation they are in is, of course, the right/best way to train. People will brag about their strengths and downplay their weaknesses. Especially on an anonymous chat board.

i agree with most of this post--the academic guys will say their training is the best, and the community guys will say the same--there is no end to the argument. however, the facts don't lie--there are community programs out there that score 100th%ile on the in-training, have every subspecialty covered with at least 2-3 attendings per specialty (except tumor), moonlight, live in a relatively large city with tons to do, and match EVERY resident into their desired field for a fellowship, and top fellowships at that--these are undeniable facts, not opinions.

i can assure the original poster that community programs are alive and well, and don't listen to your program director--(s)he's obviously grossly misinformed, or purposely trying to deceive.

From a Fellowship Director's perspective:
We match fellows who have trained in 2-person "community programs" and more traditional "academic programs". I can tell you that ultimately the cream rises to the top no matter what environment you may be fortunate enough to match into and train. Regardless of the program size, however, it is certainly helpful if there are mentors in your program who can advocate for you in your next quest for a fellowship (which unfortunately comes sooner than you can even fathom).

We have had a tremendous track record with fellows from some of the smaller 2-person/year programs in Michigan for example and to a person they've been outstanding fellows. They usually do not have the same research opportunities perhaps, but in general their surgical training and education are outstanding.

We also attract a number of fellows who have trained in the larger "academic programs" and in general their training is also outstanding. We enjoy the diversity of both types of fellows and feel that it enhances the fellowship and indeed our residency.

Hope this helps some...

wnl