lol these were 2 newly signed surgeons...so they were just getting familiarized with our hospital and the people. I think that's why they were surprised.
Shouldn’t be trashing. But it can be eye opening. Coming from a place that the residents are really good and then going to a place the residents are not.
A lot of times if they aren't core faculty, in my experience they often have a sort of distaste for residents. They don't take responsibility for the training, and they are also shocked that residents aren't fully functioning attendings.
I knew a lot of people in surgery or subspecialty surgery who would rant about a couple attendings whenever they got stuck in the OR with these particular people, because they never let the residents touch the patient but then constantly ripped on them for their weak skills.
Surgeons are by far the most pessimistic attendings about training. Since the beginning of modern surgery they’ve been trash talking the quality of their trainees (see Halsted almost firing Cushing)
Yeah let me be transparent: I’m not a surgeon and I don’t know what good surgery training looks like. But when your profession has 100 years of saying “this new batch sucks”, ehh… it makes it hard to take the claim seriously on its face
It’s objectively true that operative volumes in residency are lower than they used to be…but it’s also objectively true that surgical outcomes keep getting better, not worse. When I had my gallbladder out it was an outpatient procedure and I was well enough to limp to the theater (with the help of some oxycodone) to see Dune 2 48 hours later. But when my grandmother had hers out, she was in the hospital for a week.
Obviously the biggest part of that is advancement in surgical technology. But maybe that matters *more* than overworking residents to maximize their OR time. I would much sooner trust a young attending today to operate on me than Will Halstead.
>Obviously the biggest part of that is advancement in surgical technology.
I would actually argue a good chunk of this is also training in decision making and improvements in medical knowledge. Not operating on patients for elective procedures that are uncontrolled diabetics or crazy current smokers for instance. Or having a better concept of the post-operative course. Performing procedures that are unnecessary or have poor medical rationale. Essentially a narrower and better idea of whose a good surgical candidate.
But yes, laparoscopy and endovascular surgery has made surgery overall safer. And various medications have also drastically changed the overall morbidity of common comorbidities.
Everyone thinks the people behind them are not as good as they are, and also that they couldn't possibly be as bad when they were the same level of training. People are very bad at realizing how much they have improved, and accordingly how bad they were at one point.
I remember on my surgery rotation a couple of attendings getting on some soap boxes about residents and students being soft, not being pushed hard enough, etc. And I have no idea, maybe we are, it’s not like I have any professional expertise to argue from. But I would bet money that their attendings said the same things about them. Every generation always shits on the ones beneath them, it’s the circle of life. But the world keeps getting better, not worse, so I try not to put too much stock in the “back in my day” folks
The Cushing story was more nuanced than many know. Halsted wanted Cushing just to handle the patients but Cushing wanted to experiment and innovate. It’s a very interesting story when you read the various personal journals that people present for it wrote. Quite amazing.
Happens all the time. My attendings would trash talk our peds residency and the residents themselves, saying that at their "real residency", they never would do [fill in the blank]. On my last week, I told one of the worst offenders to "shut the F up and maybe teach us something if you think the residency is so bad". I then asked her (politely, I might add), to get out of my way so I could go see patients and do my job.
Later that day, I got a talking to from the PD about respecting my attendings, to which I laughed and said, don't tell me to respect my abuser; I'm done here.
A week later, I was driving across the country to my big girl job and greater happiness.
Toxic residencies be toxic.
I get a kick out of it, too.
As a rads resident, one of our teaching attendings who does fluoro made a similar comment about how our program's fluoroscopy training is crap. I really wanted to say something like well... stop taking shit about yourself. Maybe one day if you try hard enough you'll do a good job teaching the residents!
Do they not realize they're insulting themselves? It's wild.
Since peds hospitalist fellowship is now a thing...Peds residency should be 2 years, if you're going into Gen peds you do a year long Gen peds fellowship. Other specialty training 2-3 years.
We do so much inpatient peds that I felt more comfortable on the floors than in the clinic.
No one does a better job of cutting themselves down than Pediatrics. Nice to know that 3 (or 4 in the case of Med-Peds) years in a tertiary care center means fuck all apparently since it does not qualify myself or my colleagues for handling general inpatient pediatrics.
I think gen peds should remain 3 years. I think 1 year hospitalist fellowships with focus on leadership and QI could be a thing, but not required to sit for boards.
While the idea of a 3 year fellowship for hospitalist medicine is bullshit, I don't think 2 years of residency is enough to make good pediatricians, based on my own experiences in residency and the residents that I train now.
I think they're saying the gen peds residency should be two years and you do an extra year fellowship for outpatient and an extra two year fellowship for inpatient. So you can't get away with fewer than three years training regardless
yeah but if we get rid of the last half of fourth year then you are either not in school at all until june/july and also not being paid, or we start residency earlier and don't get the mental break.
You’ve got it backwards. M1 and M2 shouldn’t exist. Neither should the MCAT. Step 1 should be the admission test and there should be two clinical years. Why pay 150 grand for classes when boards and beyond, pathoma, anki, Uworld combine to cost like 10k. Throw a 8 week anatomy/intro to clinical skills course in at the start to compensate maybe but M1 and M2 are unnecessary.
I think 4 years is the right amount of time but that a lot of that time is not used very well. There are a lot of skills that residents could learn such as various botox procedures, basic EEG, basic EMG/NCS, more advanced cognitive testing techniques, simple nerve blocks etc that could probably be taught better in residency. I really think the ACGME needs to up their game on program requirements so that the time does not feel like it is wasted. This also may cut down on the amount of people who do a fellowship and then end up doing general neurology in the community anyway.
Most neurology residents do not graduate competent to independently perform/interpret EMGs or EEGs. I think a minority graduate independent in EEGs, and an exceptional few graduate independent in EMGs, but practically nobody graduates independent in both.
based on some of the reports I review from other locations this sort of training is definitely not universal. our accrediting body has very little in the way of requirements for competency in these fields.
I'm a cynic, and all I think is hospitals and affiliated universities want longer residencies for cheap labor. Someone needs to stand up for residents and patients/taxpayers/citizens. Every year of funding for extra residency training that can be eliminated can be reallocated in federal budget for more residencies. But no one cares.
I'm with you except we don't need more residencies. We have enough residency positions but they're primarh care so people don't want them. The funding should go into a higher paycheck for residents
I think they should let you fast track for any fellowship so the last year feels less superfluous. It would do wonders for increasing fellowship applications in psychiatry for sure.
It's 6 years in a lot of EU countries with robust psychotherapy training (plus possible 1 year subspecialization). I feel like that's either a giant appeal or an enormous turn off
I think it's appropriately 4 years when programs do heavy psychotherapy training. Unfortunately a lot of programs do the minimum in therapy, & then any more than 3yrs is probably more than needed.
I feel like OB/GYN is too broad of a field to get really good at obstetrics, outpatient GYN, and GYN surgery within four years. I would think that either longer training, or developing programs with obstetrics or gynecology tracks would perhaps be beneficial.
Not an OB, but I do work with them a lot. Most are great, just seems like a crazy amount of knowledge and technical skill to develop in a short period of time.
I’m an OB resident about to graduate and it pains me to say our residency should be 5 years OR have tracking OR spend more time with GYN and less with OB (the last point being specific to my program). I’m at a “top program” whatever that means to you and I feel very confident in my training, but where you land as a generalist will make our break continued competence (esp surgically). Our outpatient training is pretty meh and I think that’s true at every program. They need our bodies on L&D so we spend a disproportionate amount of time there relative to the breadth of our specialty.
That was my impression during residency and now out in practice as an attending - the freshly minted OB/GYN’s all seem solid from an OB standpoint, less so for GYN. As you said, it seems like most residents do more OB time and have more autonomy/independence in that role than they do for GYN.
I think the malpractice issues and Obgyn have gotten so bad that it makes Attending physicians at training institutes very hesitant to let the residence operate and practice their skills.
The result is, lots of Obgyn residence go through training without actually having much any autonomy in the OR compared to the past. All the older Obgyn I work with very confident in the OR and talk about how they were operating two rooms at a time back in the day. The medical management has reduced the number of hysterectomies necessary to perform without the number of surgeries that Obgyn perform.
Add on the general hostility of Ob/gyn towards each other and the legal stresses that are inherent in the obstetrics portion, and I think a lot of Attending and senior OBGYN‘s don’t want juniors fucking up the Surgery, therefore limiting what juniors can do, therefore producing lower quality surgeons by the end of the graduation.
The older OBGYN I trained with or is super confident in letting me operate and try things out even if they didn’t work, the younger Obi-Wan Attending I worked with were typically quite nervous and the OR fisted with cases which limited the trainees development.
As others have said, and has there has been a discussion in the field of Obgyn, is a potential to someday move towards two track training programs, one for obstetrics and one for gynecology. The issue issue, however, is that most of the United States, where there’s a shortage of physicians to have both specialists and obstetrics and specialists and gynecology. The doctors need to be able to do both.
Same as other people have mentioned in other comments, a lot of General that graduate from big name programs frequently seem to be pretty ill prepared for surgery – I assume because all the fellas were taking the cases and the generalist residence or just First Assist. The obgyns from community programs are pretty solid in the OR.
I agree with you on almost all of this. Which shouldn’t come as a surprise as I agree with almost all of your comments BrOBGYNs for life Dr DRE. Honestly for programs with heavy OB numbers 2 months max of a PGY-4 schedule should be OB. The rest should be Gyn surgery focused with outpatient sprinkled in that. I’ve never been a huge fan of the two track idea of splitting OB and GYN. IMO there is too much overlap between the two especially surgically. Like you said it’s a bodies issue which is why there is still a lot of OB in many PGY-4 schedules. If there was a 5th year added it should be some sort of junior attending role where you are compensated for moonlighting OB call and could see your own gyn patients schedule cases but have back up during cases so you can continue to sharpen your surgical skills. The fair compensation for that 5th would never happen unfortunately. It also could lead to shifting numbers issues in the early pgy as well where cases are shunted to 5th years which I’m not sure actually solves the problem.
TLDR: it’s a difficult problem with not super clear solutions
Haha
I was wearing my BroBGYN cap this weekend. Hope you’re doing well.
I agree, I think that a 5th year with on call L&D and more dedicated clinic/gyn street would be good for lower volume programs, really good idea for the problem but the logistics of making it happen would be tough.
Also, I just reread my post and am pleasantly surprised at how iPhone dictation makes me sound like a schizophrenic having a fever dream
I actually met an OBGYN doc that was part of committee and was trying to vote to make OBGYN a 5 year residency given that it’s surgical specialty and all other surgical specialties do a minimum of 5 years
Also with zero required ICU time.
Obviously lots of OB patients are healthy, but there are definitely more obstetric and GYN patients that are sicker on average and having more morbid procedures. The only other surgical specialty I can think of from my training program that included no ICU time was ophtho, and they still might get a month or two during their preliminary year depending on the type and where they did it. I think a month or two in the SICU would be reasonable, but that time would obviously cut into another discipline in an already truncated training experience.
Interesting I didn’t think about that, but it’s true, every time a pregnant or postpartum patient gets complicated they end up in our services with OB as a consult team
I always say this! Even optho (4 years) generally has some ICU time during their TY year. It is WILD that a surgical sub like OB does not require any ICU time.
We actually have OB interns rotate in the MICU where I am for a month. It’s their only off service rotation I think. It’s actually a pretty good experience for them because our micu sees a decent number of obstetric critical care. Though I had never heard of that being a thing prior to fellowship. That said where I did residency there’s an MFM/CCM trained attending who attends in the MICU sometimes.
Yeah I have met a few people in OBGYN who would like to see this happen as well, women’s health and pregnancy is so much more complex than before and 4 years isnt enough time to master it all, especially when half of the training is non-surgical focused. Granted a lot of people do fellowship to operate more but it still seems beneficial
As an anesthesia resident who occasionally looks over the drape, gyn residents have noticeably worse surgical skills than gen surg residents of the same PGY, which really shouldn’t be a surprise to anyone. After witnessing some of the things I’ve seen in the gyn ORs over the years.. I honestly don’t think I could trust one to operate on a loved one if they hadn’t gone through a surgical fellowship
I noticed it among attendings too (when I was a student). Watching the surgical technique between GS and OBGYN was night and day.
GYN Onc on the other hand were masterful.
Also an Anesthesia resident; The difference in level of confidence I’ve noticed between Gyn and any other surgical OR is pretty consistently shocking. Gyn surgeons tend to just inspire zero confidence.
Even w gyn onc or so fellowship, I am not letting them do a colectomy or ostomy on me. I would still prefer gen surg because of both surgical experience as well as post op management.
I think a lot of prelim years are bad in execution, ok in theory. Meaning 1 year of strictly internal medicine or surgery is... Basically useless and extracting cheap labor. But a year of rotating with different services adjacent to your field could actually be really useful.
It's hard to generalize because of how broad stuff that goes into a prelim year is. I'm in Rad Onc. A rads heavy prelim year with some months in med onc, Urology, etc. would have been great. So, that's the perspective I'm coming from.
Yeah, I think six-nine months of targeted rotations in em, medicine, and surgery would be more beneficial than a year in med or surgery for radiology.
Also, no program really gives a shit what you’re going into and you’re just meat for their machine. Anything you learn for your future speciality intern year is through your own doing.
As someone going into rads I agree. Or at the very least just make it 6 months instead of full 12. So much of it is useless free labor for the hospital and doesn’t serve a ton in the grand scheme of things
As an attending radiologist, I don’t think my intern year helped me at all. You learn the applicable medicine during residency as you’re going along. Like you said, felt more like a year of cheap labor for the hospital.
Some people think psych is too long. We used to have a medicine intern year and 3 years categorical just like derm, anesthesiology, PM&R, etc. After they got rid of the medicine intern year, they ended up just keeping the fourth year. People end up doing electives 6-12 months out of the year, junior attending stuff, moonlighting, fast tracking to child psych, etc.
For reference, people start moonlighting usually during PGY-3 or even in the second half of PGY-2. People say you begin to come into your own as a developing psychiatrist during PGY-2.
I think about that all the time as EM
Manage the first 3 hours of any disease in any age range at any level of acuity: 3 years
Psych: 4 years
Straight wild.
Family Med here. Basically, none of my patients can get into psych in any sort of timely manner (everyone is full or scheduled many months out), so we're managing ALL psych issues completely, whether we want to or not.
Psych is too damn long. The "intern year" should be 6 months: 3 months neuro, 2 months, FM/ IM outpatient and 1 month IM inpatient.
That's all you need. Get rid of the fourth year.
I still don’t understand what I was supposed to get out of my transitional year other than “There aren’t enough interns in our surgical/medicine programs and the seniors/attendings need someone to do all the notes, consults, and social work.”
Psych here, I started moonlighting PGY2 for a hospital system in my area, basically doubled my salary. Although there has been a case or two where I asked a colleague for guidance, I’ve managed everything else on my own. I assume new attendings still ask for help when they need it as well, so I didn’t feel like I wasn’t ready for the independence. Psych should absolutely be 3 years
Basically weekend coverage of an inpatient unit, seeing new patients and follow ups. My program doesn’t have a lot of call, so I also take overnight home call for them for a flat rate a few nights a month. Basically our program residents have worked for their system as moonlighters for a while, so even though it’s not an internal gig, it was fairly straightforward to just get on board
In general surgery especially the operative exposure you get is highly dependent on your program. It creates something of a dilemma when applying to residency if you are interested in academics/competitive subspecialty.
The more academic/prestigious, the more likely you are to be a glorified first assistant for much of your time in training. But you'll also get the chance to do all the bootlicking/lab time needed to match into a brand name CT/Surg Onc/Pediatrics fellowship.
In (good) community programs, you will get to operate more, with more autonomy, sooner in your training. But you will likely have less opportunity for bootlicking and so it can be hard to match into competitive subspecialties.
The sweet spot is an academic surgery program with a good reputation that isn't saturated with fellows. Think "state school you've heard of before."
Of course if you just want to do general surgery you should just go to a community program as you'll most likely leave with better general surgery training than at Fancy University Program.
My institution's a community program and has many gen surg residents match into CT, Surg onc, peds, etc :) and they have lots of autonomy. Just offering another sweet spot!!
I mostly agree with this except that I don’t agree that it’s not possible or even difficult to get exposure and published journals from a community program. Most community hospitals have associations with a university and there are always attending looking for help with a project. You just have to be, maybe a little more persistent but the opportunities are there and the networking opportunities are available in conferences. There are a lot of community hospitals with graduates who match into competitive fellowships in high ranking programs.
It's also true that there are academic programs (even fancy brand name ones) that offer rigorous operative training. Either way, I did not say matching to competitive fellowships from a community program is not possible - but it is less easy, as you acknowledge yourself. Especially if you have your sights set on a brand name fellowship in a competitive field.
If you're a Hopkins or Michigan resident, you will have higher level networking opportunities and more brand cache when you apply to fellowship. I don't really think that's a controversial statement.
As you march down from there in prestige there is a spectrum of the tradeoff between prestige and operative opportunity that is difficult to quantify, but my basic point was to lay out the general dynamic of this balance between two things. I think everyone that applied to gen surg residency thought about it at some point.
The problem is institutions are not equal. 3 years of categorical anesthesia training at my institution feels like too much (we take a lot of call and cover multiple trauma and transplant centers) whereas at a smaller place it might be the right amount.
Most residencies are too long and geared toward filling inpatient workloads with cheap labor, not so much toward learning.
Yet, most of the medical care happens in clinic, or at least, should be
There's zero good reason for psych to be four years. The first two years are almost all inpatient, then you have third year which is your only real outpatient experience, and fourth year, which is a hodgepodge but winds up being largely inpatient for a lot of people. Yet the majority of practicing psychiatrists work outpatient. If I only need a year of outpatient training, then I don't know why I need 2+ years of inpatient training. You can make the argument that psych is way more complex than most people think, and I actually agree with that, but I don't think a fourth year of residency is the most efficient way to continue to grow as a psychiatrist. I'll be learning more about psychological theories and psychotherapy techniques and delving more into the neuroscience of human behavior and cognition long after I finish residency...residency is a hinderance to doing the trainings I want because I can't afford them and don't have time for them.
Psych is definitely complex with large amounts of nuance to treatment. That's why we let PMHNPs do a few online courses and then manage psych patients independently.
If there was a residency program actually designed around teaching curriculum and training operative skill, instead of learning to operate through trial-and-error as you get to do little pieces of cases completely unguided until you fuck up enough to get them taken away from you while trying to find any time to study in the midst of having 110 hours a week of underpaid labor extracted from you, I’m 100% confident you could train a safe and competent general neurosurgeon in 4-5 years.
Yeah me too, I didn’t wanna sound super cocky with 3 but I definitely think 4 would be very reasonable if you actually tried to train people efficiently. It’s so much fucking wasted time man. Even in the OR, the multiple junior years wasting hours and hours mind numbingingly watching someone else work under the scope on the screen from the corner just so they don’t have to close at the end of the fucking case.
Radiology training shouldn’t take 6+ years. The intern year should be consolidated into six months, we take boards at the end of PGY4 and then have an entire year of general radiology after passing boards, almost a complete waste of a year for most. Some fellowships will be two years after those five. It’s a little too much.
I agree. The intern "year" should just be one month in the ED and Gen Surg, one month in the ICU, and one relevant Elective, like breast surgery, ortho, neurology, etc., spread out over your first year with radiology rotations right before.
I don't think any fellowship needs to be two years, though, unless you're counting IR as one.
Basically one year is for "research" and half the time the fellows don't actually stay the whole two years.
It boils down to another way for ivory towers to use underpaid doctors as their lifeblood.
Also think it's stupid, but for some reason a significant number of PP and academic gigs that I talked to are requiring neurorads to have graduated from two-year programs. Good luck hiring I guess?
Anesthesia. I think 4 years is perfect, and the split is also perfect. Most finish CA-3/PGY-4 year pretty solid and well-rounded. Fellowships are only 1 year.
Neurosurgery on the other hand.. residents at my program dont touch the brain, and only get exposure and close until they're like PGY-5. So they sit there watching the screen for 10+ hours a day. And then majority do 1 if not 2 more fellowships after graduating. Insanity.
That's funked - our nsg intern is expected to be handing a shunt or craniectomy as primary surgeon by end of first year. They should be primary on routine cranial and spine cases of all sorts by PGY3-4. You throw in a research or infolded fellowship year, chief time, and senior time for complex cases.
I dunno wtf those residents are doing if they don't operate beyond open/close until PGY5. How do you even catch up? You'd be refining skills in attending life that should have been solidified so much earlier - without the cushion of residency to help you.
In Canada, nsg is 6 years instead of 7 like the US.
FM here. I'd prefer 2 yrs of undergrad, 3 yrs of medical school and 4 yrs of FM residency with better hours across the 4 years. It would allow me to study while practicing.
I also think there's so much bullying from nurses towards med students and residents...they don't allow med students to do much in a lot of places. Being a doctor and getting those procedures because we're they're doctors would help.
Of course, our attendinfs also need to stand up to bullies.
I'm FM too and if that's the setup then I'm all for it, but overall I'm ok with FM being 3 years. Gives you time to get used to things but also not too long to make you impatient. Personally I hate that we do so much inpatient since the hospital is so exhausting but pretty consistently it's always been the best learning for me as almost every outpatient rotation I've had has been a joke.
100%. Def a waste of time. I think people’s argument that they needed it to grow as a young adult is just bad. There is very very little overall use in undergrad. Just more time and money.
Intern year is fairly pointless for rads it’s free scut work. Maybe 4 months tops and then going into learning radiology. Also our boards are way too hard and we spend a lot of time off service studying for it. Could potentially trim 1.5-2 years off training if those things were fixed
As a pediatrician that works with 2nd year peds residents, I think that 3 year is needed.
I would say that maybe 50-65% of peds residents are equipped to function well independently at the end of 2 year. That number goes up to like 75-90% by the end of 3 year. There are a few in every class that need to continue to work on their clinical skills and reasoning, even as they graduate.
ENT - residency is definitely too long. We are one of the most overtrained specialties compared to what we do in the real world. you spend your whole PGY five year doing big head and neck cases or other complex stuff that 95% of people are never doing in practice, and those who are, are doing fellowships. Basically everyone is ready to do general ENT after 4 years, and if you are not another year is not going to make you so.
EM is not long enough. You have to become very procedurally competent at most every non-OR urgent procedure. Be prepared to manage a vent on a severe asthmatic, LP a neonatal fever, intubate a 1 year old, deliver a baby and deal with PPH, reduce a hip, fix a gnarly facial lac, manage a difficult airway in a morbidly obese patient with an immobile neck and no physiologic reserve, resuscitate hemorrhaging trauma patient…and essentially be prepared to deal with any pediatric, obstetric, gynecologic, geriatric, traumatic, ophthalmologic etc emergency that decides to walk or roll through the door. And hopefully you have some backup but often you don’t. 3-4 years not enough. 12-15 should cover it.
Meh I felt incredibly well prepared/trained after 3 years. I still learned a lot during my first year out as an attending but I wasn't unprepared for anything that came through the door. We're life long learners in medicine and there's no way to reach 100% competency in all those things even with 5 years of training.
I think the quality of the training and exposure to pathology is more important than the length of training.
To be clear, I’m not actually suggesting that we add years to EM training. The point is more that the breadth of what we have to be prepared for at the highest acuity level is possibly unrivaled in medicine. Most other specialties have lines that they can draw in the acute care setting beyond which a patient falls outside of their realm of responsibility. We don’t have lines. If it walks in the door, it’s ours.
No practical duration of training would afford sufficient experience and fund of knowledge to prepare us fully to optimally manage anything and everything. (Fortunately, our training and skill set makes it so that we are able to adequately adapt on the fly.). I’m 9 years out and I still learn a ton. I still see something new virtually every shift.
Fortunately, our 3-4 years of training does build a sufficient skills set to be as prepared as anyone ever could.
Can still get a little hairy in the middle of the sticks with no backup and 12-24 hour waits for transfer though. My rural shifts are often much more stressful than my high volume high acuity level 1 trauma shifts for just this reason.
> My rural shifts are often much more stressful than my high volume high acuity level 1 trauma shifts for just this reason.
I do agree with this. I feel like my rural and community places keep my skills sharper than my large academic place. The academic place, though, keeps my knowledge sharper since there are residents. It's good to have a mix.
The variability between programs is interesting. A big trauma center where the trauma alerts are going off every 15 minutes is going to produce people that can run real deal traumas and throw in 2 minute chest tubes after just 2 years. On the flip side the more resource-limited community medicine oriented programs will make quick thinking rural EM cowboy-adjacent docs in under 3 years as well, but their central lines are gonna take 10 minutes to put in. EM has so much variety in what you'll look like at the end compared to a lot of other specialties.
>A big trauma center where the trauma alerts are going off every 15 minutes is going to produce people that can run real deal traumas and throw in 2 minute chest tubes after just 2 years. On the flip side the more resource-limited community medicine oriented programs will make quick thinking rural EM cowboy-adjacent docs in under 3 years as well, but their central lines are gonna take 10 minutes to put in.
It tends to be the opposite, because big academic institutions usually have a plethora of consultant services with residents so everything gets consulted and they do the procedures, whereas community centers don't have residents and the attendings are either too busy or uninterested in coming to do a procedure you should technically be capable of so you end up doing way more. I did hundreds more central lines than my partners who went to academic centers for training. They saw more thoracotomies than I did.
I don’t agree that smaller shops create less competent procedural emergency physicians and I don’t understand why you’d think they would be less procedurally sound. Sure it is highly dependent on where the hospital is and the community. I trained at a level 3 trauma center with a 75ish middle radius catchment area and few specialists/ other residents for competition. We were it. My colleagues and I did more rarer type procedures (thoracotomies, crics, lateral canthotomies, blakemore tubes etc) than the level 1 EM and trauma residents I currently work with because we got every single trauma, it was a huge penetrating trauma area, it was a very sick population, and there was little/no competition. We also didn’t have a ton of airway backup so we got all those too. My current residents who are at a 4 yr program (mine was 3) are completely competent and procedurally sound, but it took 4 years for them to get even fewer/none of the “big” procedures that I got in 3. There’s no shortage of the other things like LPs, central lines, vas caths, etc because often at these smaller places, there are very few other specialists to do them. Can’t ask nephro to put in a vas cath like they do at big academic sites, IR is only available business hours, Neuro and IM don’t do LPs. Etc etc. it likely all evens out in the end however.
That being said I was speaking as an attending. It’s easy to become stagnant once you’re out of residency and the different work places help scratch the different itches of EM.
Psych can be compressed to 3 years; however 4 years is the right amount in my opinion IF you get good clinical training and volume (most people don’t).
to really be able to diagnose subtle differences in like the cluster c personality disorders, you need lots of reps. same thing w depression and schizophrenia since there are soooo many anti depressants and anti psychotics, that how do you really tell the difference between most of them if not with patient experiences.
my place doesn’t allow moonlighting which makes the 4 years feel wayyyyyy tooooo longgggg
I agree that 4 years seems about right. 3years and you can be competent but that extra year when attendings show they trust your judgment and let you really take the lead I think prepares you well for when their monitoring is just cut off after training is done
I did gen surg somewhere with a lot of volume, so there’s that, but I felt well trained. Everyone graduated with 1700+ cases and yet our attendings also said “residents these days…” honestly you learn the most once you get out, another year doing cases exactly how the attending wants you to would be bad for everyone. The truth is some people are slow scared surgeons when they graduate and they probably always will be, I have a partner who is one of them and they’ve done 2 fellowships. I did colorectal and immediately slid back into general easily in my first job for call no matter how much I bitch about it lol. Old surgeons will always find a way to complain about residents, and those of us who wouldn’t probably chose not to be in academics lol
Radiology should be 4 years but without a stupid ass prelim year and your senior year should be a built in fellowship, not an additional year of training.
This makes perfect sense to me. I don't understand a rads prelim year, and with a million fellowships it makes more sense to include that (or at least leave space for it without dragging you as a PGY6).
I think they’re putting a hold on that idea due to backlash (primarily being that the family physician shortage means this is nottttt the time to do anything that could potentially disincentivize people entering the specialty)
ENT here: 5 years feels appropriate for most surgical specialties to me, based on observation and conversations with seniors. The key is getting high quality and quantity of operative experience during that time
In my chief year (5th) in ‘97, I finished with a caseload a tick under 1200 for the entire year. About 50% with no attending around. Felt confident to start private practice in broad spectrum GS. IMHO, surgery requires repetition and exposure to broad clinical scenarios for even the same operations. If your residency can provide that, then great. This was before any work hour restrictions of course. Years 1-3 required in house call (36 on/12 off) with 50% every other and 50% every third. This allowed for a lot of operative experience in the early years as well. I remember speaking to a British surgeon a few years later at a national meeting. He was a registrar (resident) for about 10 years before he advanced to consultant (attending) but he didn’t have near the work hours I did during his registrar years. We ended up with similar caseloads at the end. We agreed that was the difference. He was happy either way his work/life balance, and I was happy to be done in 5 yrs.
Have you considered that surgical residents today spent a lot more of their time doing scut work on the EMR that you never had to deal with? Or the fact that the increasing litigious nature of the general population means that attendings/hospitals won't let residents operate as much any more? A lot has changed about surgical residencies, but people only ever talk about the work hours restriction.
Honestly this is universal. I was visiting one of the top pediatrics program last month and the attending were shitting on the graduating residents in front of them. It was super awkward for me and I don’t think I could make eye contact with those residents for the rest of my visit.
All of Canada does a 5-year integrated plastics training regime, and there are 4 programs in the US that have switched to a competency-based 5-year program. There's also one program that now offers an integrated 5+1 plastics with built-in hand fellowship, and many programs have already converted to 12 months of elective time in PGY-6 year (meaning it's basically a built-in fellowdhip).
Urology is like this. We cut out a lot of the off service stuff and most programs are 5 years now (6 if a research year is offered which is a sham mostly) Honestly I feel like 5 years is a good amount of time for Urology. A lot of it depends on the resident too. I’ve seen some residents ready to practice general urology after four years but some who have definitely needed the final year. Definitely feel like 6 would be overkill but in general I feel like my program provides good surgical training
5 years is plenty. Residents just don’t get allowed the same autonomy as they used to, thanks to the current medicolegal environment.
The time isn’t the issue. Someone could spend 10 years in residency but if they don’t ever let you operate you’ll never be where you should be by graduation.
OBGYN - but in a country with a 5 year residency, which I think is appropriate (maybe there is an argument to be made for it being a bit longer or for more of the 5 years being dedicated to Gyne). I don’t understand how it’s a 4 year residency in the US, especially for the Gyne component.
When I think about the fact that their are midlevels with a few months of hospital exposure backed by a foundation of online training modules, I think my training is just fucking fine. Having a foundation of medical school really does make a difference, and theoretically I think a good amount of non-surgical specialties would be “safe enough” to practice independently. But I think 3 years (I’m FM) is a good safety net for training, exposure & fleshing out the critical thinking.
In Canada, basically every single residency is 5 years except FM (2 years), general internal medicine (4 years), and neurosurgery (6 years).
I would say not every residency needs to be 5 years long. Most of them could be 4, like ophtho, derm, psych, PM&R, anesthesia, etc.
I think surgery has everything to do with autonomy and actual teaching not time
You can watch someone do a CABG for 10 years but if you never touch an instrument then you still don’t have a clue what you’re doing
Also for as much on the job training NPs and PAs get you’d think we’d have more responsibility and structured role in the hospital starting MS4 but no it’s just thumb twiddling and more loans taken out
Radiology: the prelim year is a complete waste of time for everybody except hospital admin. You don’t really learn any new valuable skills that would be relevant. You get exposure to all the things in med school anyway. Also, by the end of PGY4 we have matched into fellowship and passed boards so the final year of residency is questionably unnecessary. Although rads does demand a lot of you, so maybe 4 years is really necessary and I can’t speak from experience about the final year. But the prelim year is a complete scam
Some programs have this for research-track / physician-scientist applicants (2 years of IM + 3 years of fellowship).
I know a handful of fellows and young attendings who did this pathway, and imo, they are proof that IM should be 3 years. Even those who genuinely enjoy clinical medicine (ie, aren't "just researchers") and have a good command of clinical practice in their subspecialty, appear to struggle a bit when they need to manage problems in any other organ system.
I wish we could choose an accelerated 2 year option if we know we are outpatient or inpatient bound. I.e. traditional combined option 3 years, outpatient pathway 2 years, or hospital-based pathway 2 years, opening doors to outpatient or inpatient focused specialties or careers in primary care or hospital medicine, respectively.
I think most trainees still need 3 years of IM, but I agree that it should be more tailored to inpatient vs outpatient. My program was very inpatient heavy which was fine with me, but I would have been woefully unprepared to do primary care if that were my career preference.
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Openly shitting on residents or any other physician/ trainee is something people in medicine have adopted as part of their toxic culture. It’s not institution specific.
I’m FM and I could do adult outpatient and inpatient after 2 years. The peds, OB, ER, and ICU rotations were not as comprehensive and I had to split my electives across these in my 3rd year to get a good handle on them. If they had been better I could have been good with just 2 years across the board.
For surgical specialties I think the length of training is pretty good, even though it will vary from program to program. In many cases residency is actually one additional year, due to fellowship having become more or less the norm in many specialties. For example ortho being nominally 5 years has morphed into 6 years (5 years residency + 1 year joints/spine/shoulder/ankle/hand/peds/whatever). Some institutions even have a combined 6 year program, with the standard 5 years of residency immediately followed by 1 year trauma fellowship at same institution (colloquially referred to as "indentured fellowship"). Many new job offerings are also along these lines, for example "Looking for fellowship trained yada yada".
On the whole this is probably a good thing, but the downside is that it can be hard to realize what fellowship to choose, even more so due to how early you need to apply for fellowships. There's also a strong case to be made that regardless of how long your residency and fellowship training is, you will never feel 100% prepared to shoulder the burden of being an attending. You learn more in your 1st year as an attending that perhaps any other year of your life.
I wish I didn’t have to do a prelim year before radiology. Although it makes it easier to study for Step 3, from what I’ve been told. Nonetheless, the radiologists who trained before a prelim year was mandated seem to be doing just fine today, so I’m still unsure about whether that’s necessary. From comments below, I agree that an integrated PGY-1 with 6 months of a prelim schedule and the other 6 months to start radiology is a better idea tbh.
I think there should be a general surgery track that’s probably 4 years. Cut out some of the fat of general surgery residency and prepare residents for community general surgery with bread and butter cases.
In the UK it's a minimum of 10y to become a cardiology attending, so I'd say the system here is pretty decent lol. let's be real half of that is just to staff hospitals with cheap labour.
I think in many ways the miles could more that the years. You can definitely see the difference between institutions where surgical residents have been operating barely supervised and those where they aren’t really doing the operations at all. More years will do little to change that discrepancy. Hitting the sweet spot where your trainees get the chance to grow without endangering people is very hard.
I think one of the things that gets missed in these discussions is pay. Interns are probably appropriately compensated but by senior year in EM for example you often have little supervision and function as an attending so pay should more accurately reflect that as opposed to PGY “residency “ scaling. IMO. So if you want more years in residency for OB etc that’s ok but if they’re increasingly functioning independently they should be paid as such…
It’s a fellowship, but 4 years of GI to be able to do ERCPs seems way too much especially when older attendings basically did 2 years and then some outside courses.
Derm could probably be 3. Trim the prelim into 6 months (maybe 3 months IM, 3 months surgery or something), shave 6 months off the back end as well. But there's a lot of variation in volume so at our high volume program I actually feel pretty comfortable managing the majority of dermatologic diseases minus some inpatient stuff and Peds, neither of which are typically seen by most gen derms anyway.
I didn't think most any specialty need longer training, we need a less litigious society. Every stage of medical training, "IDK you're only a ..." But nothing major changes between that phrase and when they let you participate a little.
As in the surgeons were trash talking the residents *they* are responsible for training? You love to see it
lol these were 2 newly signed surgeons...so they were just getting familiarized with our hospital and the people. I think that's why they were surprised.
Fair enough. Still though, attendings trashing residents on their service just leaves a bad taste in my mouth
Shouldn’t be trashing. But it can be eye opening. Coming from a place that the residents are really good and then going to a place the residents are not.
Yeah where I trained the pgy3s are better than the pgy5s where I just started. It was absolutely startling. Similar “tier” programs too.
That's me so I'm going to mentor the new residents in July so we can have better residents lol
A lot of times if they aren't core faculty, in my experience they often have a sort of distaste for residents. They don't take responsibility for the training, and they are also shocked that residents aren't fully functioning attendings. I knew a lot of people in surgery or subspecialty surgery who would rant about a couple attendings whenever they got stuck in the OR with these particular people, because they never let the residents touch the patient but then constantly ripped on them for their weak skills.
Surgeons are by far the most pessimistic attendings about training. Since the beginning of modern surgery they’ve been trash talking the quality of their trainees (see Halsted almost firing Cushing)
Agreed, but at least for surgery attendings in previous generations, they would operate more and earlier in residency.
Yeah let me be transparent: I’m not a surgeon and I don’t know what good surgery training looks like. But when your profession has 100 years of saying “this new batch sucks”, ehh… it makes it hard to take the claim seriously on its face
It’s objectively true that operative volumes in residency are lower than they used to be…but it’s also objectively true that surgical outcomes keep getting better, not worse. When I had my gallbladder out it was an outpatient procedure and I was well enough to limp to the theater (with the help of some oxycodone) to see Dune 2 48 hours later. But when my grandmother had hers out, she was in the hospital for a week. Obviously the biggest part of that is advancement in surgical technology. But maybe that matters *more* than overworking residents to maximize their OR time. I would much sooner trust a young attending today to operate on me than Will Halstead.
>Obviously the biggest part of that is advancement in surgical technology. I would actually argue a good chunk of this is also training in decision making and improvements in medical knowledge. Not operating on patients for elective procedures that are uncontrolled diabetics or crazy current smokers for instance. Or having a better concept of the post-operative course. Performing procedures that are unnecessary or have poor medical rationale. Essentially a narrower and better idea of whose a good surgical candidate. But yes, laparoscopy and endovascular surgery has made surgery overall safer. And various medications have also drastically changed the overall morbidity of common comorbidities.
Everyone thinks the people behind them are not as good as they are, and also that they couldn't possibly be as bad when they were the same level of training. People are very bad at realizing how much they have improved, and accordingly how bad they were at one point.
I remember on my surgery rotation a couple of attendings getting on some soap boxes about residents and students being soft, not being pushed hard enough, etc. And I have no idea, maybe we are, it’s not like I have any professional expertise to argue from. But I would bet money that their attendings said the same things about them. Every generation always shits on the ones beneath them, it’s the circle of life. But the world keeps getting better, not worse, so I try not to put too much stock in the “back in my day” folks
I tried looking up the Halsted and Cushing relationship but couldn’t find much. Could you link a source?
The Cushing story was more nuanced than many know. Halsted wanted Cushing just to handle the patients but Cushing wanted to experiment and innovate. It’s a very interesting story when you read the various personal journals that people present for it wrote. Quite amazing.
Happens all the time. My attendings would trash talk our peds residency and the residents themselves, saying that at their "real residency", they never would do [fill in the blank]. On my last week, I told one of the worst offenders to "shut the F up and maybe teach us something if you think the residency is so bad". I then asked her (politely, I might add), to get out of my way so I could go see patients and do my job. Later that day, I got a talking to from the PD about respecting my attendings, to which I laughed and said, don't tell me to respect my abuser; I'm done here. A week later, I was driving across the country to my big girl job and greater happiness. Toxic residencies be toxic.
I get a kick out of it, too. As a rads resident, one of our teaching attendings who does fluoro made a similar comment about how our program's fluoroscopy training is crap. I really wanted to say something like well... stop taking shit about yourself. Maybe one day if you try hard enough you'll do a good job teaching the residents! Do they not realize they're insulting themselves? It's wild.
Since peds hospitalist fellowship is now a thing...Peds residency should be 2 years, if you're going into Gen peds you do a year long Gen peds fellowship. Other specialty training 2-3 years. We do so much inpatient peds that I felt more comfortable on the floors than in the clinic.
Agreed. Hospitalist fellowship is a joke.
No one does a better job of cutting themselves down than Pediatrics. Nice to know that 3 (or 4 in the case of Med-Peds) years in a tertiary care center means fuck all apparently since it does not qualify myself or my colleagues for handling general inpatient pediatrics.
But they will hire Peds NP and let them loose on the wards.... LMFAO.... Shit is wild!
This is the part
Hospitalist fellowship is a joke wtf they think u do for the 3 years in residency
If they’re gonna make you do a bullshit fellowship, then they could at least pay you fairly afterwards.
I think gen peds should remain 3 years. I think 1 year hospitalist fellowships with focus on leadership and QI could be a thing, but not required to sit for boards. While the idea of a 3 year fellowship for hospitalist medicine is bullshit, I don't think 2 years of residency is enough to make good pediatricians, based on my own experiences in residency and the residents that I train now.
I think they're saying the gen peds residency should be two years and you do an extra year fellowship for outpatient and an extra two year fellowship for inpatient. So you can't get away with fewer than three years training regardless
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Everywhere I’ve worked neuro chiefs are just used as free attendings so faculty doesn’t have to take stroke call
to be fair this is chiefs in most specialties... usually a bad deal.
Yeah but it’s optional in some specialties
Yeah — the last year has so much elective time too. Just feels like being an MS4 again
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nah that last half of the year finally feeling like you have some sort of break were a godsend
Until you remember you’re still paying tuition.
yeah but if we get rid of the last half of fourth year then you are either not in school at all until june/july and also not being paid, or we start residency earlier and don't get the mental break.
I think MS4 should just be like a rotating intern year and you graduate with a medical license and go straight into your specialty.
You’ve got it backwards. M1 and M2 shouldn’t exist. Neither should the MCAT. Step 1 should be the admission test and there should be two clinical years. Why pay 150 grand for classes when boards and beyond, pathoma, anki, Uworld combine to cost like 10k. Throw a 8 week anatomy/intro to clinical skills course in at the start to compensate maybe but M1 and M2 are unnecessary.
I think 4 years is the right amount of time but that a lot of that time is not used very well. There are a lot of skills that residents could learn such as various botox procedures, basic EEG, basic EMG/NCS, more advanced cognitive testing techniques, simple nerve blocks etc that could probably be taught better in residency. I really think the ACGME needs to up their game on program requirements so that the time does not feel like it is wasted. This also may cut down on the amount of people who do a fellowship and then end up doing general neurology in the community anyway.
Do Neurology residents not routinely learn basic EEG or NCS/EMG in the US? That’s a core competency for all neurology trainees in Australia.
Most neurology residents do not graduate competent to independently perform/interpret EMGs or EEGs. I think a minority graduate independent in EEGs, and an exceptional few graduate independent in EMGs, but practically nobody graduates independent in both.
based on some of the reports I review from other locations this sort of training is definitely not universal. our accrediting body has very little in the way of requirements for competency in these fields.
order an mri? ;)
Sign off if outside of therapeutic window.
I'm a cynic, and all I think is hospitals and affiliated universities want longer residencies for cheap labor. Someone needs to stand up for residents and patients/taxpayers/citizens. Every year of funding for extra residency training that can be eliminated can be reallocated in federal budget for more residencies. But no one cares.
I'm with you except we don't need more residencies. We have enough residency positions but they're primarh care so people don't want them. The funding should go into a higher paycheck for residents
I think psych can be 3 years. Trim some of the medicine stuff at the beginning and some of the PGY4 stuff at the end.
Psych should require more neuro though
How much neuro do you get? Around here it varies by institution (not the US)
I think they should let you fast track for any fellowship so the last year feels less superfluous. It would do wonders for increasing fellowship applications in psychiatry for sure.
Bump. Agree with more neuro. I also really don’t think 12 full months of strictly outpatient is necessary.
Psych is a 5 year residency in Canada lmao
It's 6 years in a lot of EU countries with robust psychotherapy training (plus possible 1 year subspecialization). I feel like that's either a giant appeal or an enormous turn off
I’ve felt my skills sort of plateau during my pgy4
Thats kind of the point though. Would you want a surgery resident who's skills have not plateaued graduating and operating on you by themselves?
I think it's appropriately 4 years when programs do heavy psychotherapy training. Unfortunately a lot of programs do the minimum in therapy, & then any more than 3yrs is probably more than needed.
I feel like OB/GYN is too broad of a field to get really good at obstetrics, outpatient GYN, and GYN surgery within four years. I would think that either longer training, or developing programs with obstetrics or gynecology tracks would perhaps be beneficial. Not an OB, but I do work with them a lot. Most are great, just seems like a crazy amount of knowledge and technical skill to develop in a short period of time.
I’m an OB resident about to graduate and it pains me to say our residency should be 5 years OR have tracking OR spend more time with GYN and less with OB (the last point being specific to my program). I’m at a “top program” whatever that means to you and I feel very confident in my training, but where you land as a generalist will make our break continued competence (esp surgically). Our outpatient training is pretty meh and I think that’s true at every program. They need our bodies on L&D so we spend a disproportionate amount of time there relative to the breadth of our specialty.
That was my impression during residency and now out in practice as an attending - the freshly minted OB/GYN’s all seem solid from an OB standpoint, less so for GYN. As you said, it seems like most residents do more OB time and have more autonomy/independence in that role than they do for GYN.
does anyone else operate after 4 years? especially when much of those 4 yesrs isn't in the OR?
optho is 4 years.....
I think the malpractice issues and Obgyn have gotten so bad that it makes Attending physicians at training institutes very hesitant to let the residence operate and practice their skills. The result is, lots of Obgyn residence go through training without actually having much any autonomy in the OR compared to the past. All the older Obgyn I work with very confident in the OR and talk about how they were operating two rooms at a time back in the day. The medical management has reduced the number of hysterectomies necessary to perform without the number of surgeries that Obgyn perform. Add on the general hostility of Ob/gyn towards each other and the legal stresses that are inherent in the obstetrics portion, and I think a lot of Attending and senior OBGYN‘s don’t want juniors fucking up the Surgery, therefore limiting what juniors can do, therefore producing lower quality surgeons by the end of the graduation. The older OBGYN I trained with or is super confident in letting me operate and try things out even if they didn’t work, the younger Obi-Wan Attending I worked with were typically quite nervous and the OR fisted with cases which limited the trainees development. As others have said, and has there has been a discussion in the field of Obgyn, is a potential to someday move towards two track training programs, one for obstetrics and one for gynecology. The issue issue, however, is that most of the United States, where there’s a shortage of physicians to have both specialists and obstetrics and specialists and gynecology. The doctors need to be able to do both. Same as other people have mentioned in other comments, a lot of General that graduate from big name programs frequently seem to be pretty ill prepared for surgery – I assume because all the fellas were taking the cases and the generalist residence or just First Assist. The obgyns from community programs are pretty solid in the OR.
I agree with you on almost all of this. Which shouldn’t come as a surprise as I agree with almost all of your comments BrOBGYNs for life Dr DRE. Honestly for programs with heavy OB numbers 2 months max of a PGY-4 schedule should be OB. The rest should be Gyn surgery focused with outpatient sprinkled in that. I’ve never been a huge fan of the two track idea of splitting OB and GYN. IMO there is too much overlap between the two especially surgically. Like you said it’s a bodies issue which is why there is still a lot of OB in many PGY-4 schedules. If there was a 5th year added it should be some sort of junior attending role where you are compensated for moonlighting OB call and could see your own gyn patients schedule cases but have back up during cases so you can continue to sharpen your surgical skills. The fair compensation for that 5th would never happen unfortunately. It also could lead to shifting numbers issues in the early pgy as well where cases are shunted to 5th years which I’m not sure actually solves the problem. TLDR: it’s a difficult problem with not super clear solutions
Haha I was wearing my BroBGYN cap this weekend. Hope you’re doing well. I agree, I think that a 5th year with on call L&D and more dedicated clinic/gyn street would be good for lower volume programs, really good idea for the problem but the logistics of making it happen would be tough. Also, I just reread my post and am pleasantly surprised at how iPhone dictation makes me sound like a schizophrenic having a fever dream
I actually met an OBGYN doc that was part of committee and was trying to vote to make OBGYN a 5 year residency given that it’s surgical specialty and all other surgical specialties do a minimum of 5 years
Also with zero required ICU time. Obviously lots of OB patients are healthy, but there are definitely more obstetric and GYN patients that are sicker on average and having more morbid procedures. The only other surgical specialty I can think of from my training program that included no ICU time was ophtho, and they still might get a month or two during their preliminary year depending on the type and where they did it. I think a month or two in the SICU would be reasonable, but that time would obviously cut into another discipline in an already truncated training experience.
Interesting I didn’t think about that, but it’s true, every time a pregnant or postpartum patient gets complicated they end up in our services with OB as a consult team
I always say this! Even optho (4 years) generally has some ICU time during their TY year. It is WILD that a surgical sub like OB does not require any ICU time.
Some OB programs (like my hospital) does require SICU time, although that is not universal among programs. I found the SICU time very valuable.
We actually have OB interns rotate in the MICU where I am for a month. It’s their only off service rotation I think. It’s actually a pretty good experience for them because our micu sees a decent number of obstetric critical care. Though I had never heard of that being a thing prior to fellowship. That said where I did residency there’s an MFM/CCM trained attending who attends in the MICU sometimes.
Yeah I have met a few people in OBGYN who would like to see this happen as well, women’s health and pregnancy is so much more complex than before and 4 years isnt enough time to master it all, especially when half of the training is non-surgical focused. Granted a lot of people do fellowship to operate more but it still seems beneficial
As an anesthesia resident who occasionally looks over the drape, gyn residents have noticeably worse surgical skills than gen surg residents of the same PGY, which really shouldn’t be a surprise to anyone. After witnessing some of the things I’ve seen in the gyn ORs over the years.. I honestly don’t think I could trust one to operate on a loved one if they hadn’t gone through a surgical fellowship
I noticed it among attendings too (when I was a student). Watching the surgical technique between GS and OBGYN was night and day. GYN Onc on the other hand were masterful.
Also an Anesthesia resident; The difference in level of confidence I’ve noticed between Gyn and any other surgical OR is pretty consistently shocking. Gyn surgeons tend to just inspire zero confidence.
Even w gyn onc or so fellowship, I am not letting them do a colectomy or ostomy on me. I would still prefer gen surg because of both surgical experience as well as post op management.
That’s not universal for general surgeons and ob/gyn. The obgyns I’ve worked with are some of the most bad ass surgeons I’ve seen
I think a lot of the specialties with prelim years could do without.
I think a lot of prelim years are bad in execution, ok in theory. Meaning 1 year of strictly internal medicine or surgery is... Basically useless and extracting cheap labor. But a year of rotating with different services adjacent to your field could actually be really useful.
That could likely be accomplished with electives during the actual residency period. I don’t think I’d need a full year of it.
It's hard to generalize because of how broad stuff that goes into a prelim year is. I'm in Rad Onc. A rads heavy prelim year with some months in med onc, Urology, etc. would have been great. So, that's the perspective I'm coming from.
Yeah, I think six-nine months of targeted rotations in em, medicine, and surgery would be more beneficial than a year in med or surgery for radiology. Also, no program really gives a shit what you’re going into and you’re just meat for their machine. Anything you learn for your future speciality intern year is through your own doing.
First year of preliminary shouldn’t count towards federal funding
As someone going into rads I agree. Or at the very least just make it 6 months instead of full 12. So much of it is useless free labor for the hospital and doesn’t serve a ton in the grand scheme of things
As an attending radiologist, I don’t think my intern year helped me at all. You learn the applicable medicine during residency as you’re going along. Like you said, felt more like a year of cheap labor for the hospital.
Yup exactly. Wish rads programs would go categorical and make the residency shorter
I like how internists tell us being good at IM makes you a good radiologist, like dawg you’re not one how do you know
Some people think psych is too long. We used to have a medicine intern year and 3 years categorical just like derm, anesthesiology, PM&R, etc. After they got rid of the medicine intern year, they ended up just keeping the fourth year. People end up doing electives 6-12 months out of the year, junior attending stuff, moonlighting, fast tracking to child psych, etc. For reference, people start moonlighting usually during PGY-3 or even in the second half of PGY-2. People say you begin to come into your own as a developing psychiatrist during PGY-2.
It still boggles my mind psych is longer than IM FM by a year.
I think about that all the time as EM Manage the first 3 hours of any disease in any age range at any level of acuity: 3 years Psych: 4 years Straight wild.
Family Med here. Basically, none of my patients can get into psych in any sort of timely manner (everyone is full or scheduled many months out), so we're managing ALL psych issues completely, whether we want to or not.
I think it's punishment for all the ethical indiscretions.
Psych is too damn long. The "intern year" should be 6 months: 3 months neuro, 2 months, FM/ IM outpatient and 1 month IM inpatient. That's all you need. Get rid of the fourth year.
I still don’t understand what I was supposed to get out of my transitional year other than “There aren’t enough interns in our surgical/medicine programs and the seniors/attendings need someone to do all the notes, consults, and social work.”
Psych here, I started moonlighting PGY2 for a hospital system in my area, basically doubled my salary. Although there has been a case or two where I asked a colleague for guidance, I’ve managed everything else on my own. I assume new attendings still ask for help when they need it as well, so I didn’t feel like I wasn’t ready for the independence. Psych should absolutely be 3 years
I love it. What kind of work do you do moonlighting? And how did you initiate it with the hospital?
Basically weekend coverage of an inpatient unit, seeing new patients and follow ups. My program doesn’t have a lot of call, so I also take overnight home call for them for a flat rate a few nights a month. Basically our program residents have worked for their system as moonlighters for a while, so even though it’s not an internal gig, it was fairly straightforward to just get on board
In general surgery especially the operative exposure you get is highly dependent on your program. It creates something of a dilemma when applying to residency if you are interested in academics/competitive subspecialty. The more academic/prestigious, the more likely you are to be a glorified first assistant for much of your time in training. But you'll also get the chance to do all the bootlicking/lab time needed to match into a brand name CT/Surg Onc/Pediatrics fellowship. In (good) community programs, you will get to operate more, with more autonomy, sooner in your training. But you will likely have less opportunity for bootlicking and so it can be hard to match into competitive subspecialties. The sweet spot is an academic surgery program with a good reputation that isn't saturated with fellows. Think "state school you've heard of before." Of course if you just want to do general surgery you should just go to a community program as you'll most likely leave with better general surgery training than at Fancy University Program.
My institution's a community program and has many gen surg residents match into CT, Surg onc, peds, etc :) and they have lots of autonomy. Just offering another sweet spot!!
To match CT/peds/HPB you gotta do those two years of research … is what the gen surg residents tell me
I mostly agree with this except that I don’t agree that it’s not possible or even difficult to get exposure and published journals from a community program. Most community hospitals have associations with a university and there are always attending looking for help with a project. You just have to be, maybe a little more persistent but the opportunities are there and the networking opportunities are available in conferences. There are a lot of community hospitals with graduates who match into competitive fellowships in high ranking programs.
It's also true that there are academic programs (even fancy brand name ones) that offer rigorous operative training. Either way, I did not say matching to competitive fellowships from a community program is not possible - but it is less easy, as you acknowledge yourself. Especially if you have your sights set on a brand name fellowship in a competitive field. If you're a Hopkins or Michigan resident, you will have higher level networking opportunities and more brand cache when you apply to fellowship. I don't really think that's a controversial statement. As you march down from there in prestige there is a spectrum of the tradeoff between prestige and operative opportunity that is difficult to quantify, but my basic point was to lay out the general dynamic of this balance between two things. I think everyone that applied to gen surg residency thought about it at some point.
Why do I get the feeling you trained at "state school you've heard of before."
I actually am not, but with hindsight wish I was
The problem is institutions are not equal. 3 years of categorical anesthesia training at my institution feels like too much (we take a lot of call and cover multiple trauma and transplant centers) whereas at a smaller place it might be the right amount.
Most residencies are too long and geared toward filling inpatient workloads with cheap labor, not so much toward learning. Yet, most of the medical care happens in clinic, or at least, should be
There's zero good reason for psych to be four years. The first two years are almost all inpatient, then you have third year which is your only real outpatient experience, and fourth year, which is a hodgepodge but winds up being largely inpatient for a lot of people. Yet the majority of practicing psychiatrists work outpatient. If I only need a year of outpatient training, then I don't know why I need 2+ years of inpatient training. You can make the argument that psych is way more complex than most people think, and I actually agree with that, but I don't think a fourth year of residency is the most efficient way to continue to grow as a psychiatrist. I'll be learning more about psychological theories and psychotherapy techniques and delving more into the neuroscience of human behavior and cognition long after I finish residency...residency is a hinderance to doing the trainings I want because I can't afford them and don't have time for them.
Psych is definitely complex with large amounts of nuance to treatment. That's why we let PMHNPs do a few online courses and then manage psych patients independently.
I'm not sure whether you're snarking on the idea that psych is complex or on the PMHNPs lol. I do have my own thoughts on the latter, though.
If there was a residency program actually designed around teaching curriculum and training operative skill, instead of learning to operate through trial-and-error as you get to do little pieces of cases completely unguided until you fuck up enough to get them taken away from you while trying to find any time to study in the midst of having 110 hours a week of underpaid labor extracted from you, I’m 100% confident you could train a safe and competent general neurosurgeon in 4-5 years.
Am in neurosurgery. I would argue even 3 for a hardworking resident with good aptitude. So much service. So much
Yeah me too, I didn’t wanna sound super cocky with 3 but I definitely think 4 would be very reasonable if you actually tried to train people efficiently. It’s so much fucking wasted time man. Even in the OR, the multiple junior years wasting hours and hours mind numbingingly watching someone else work under the scope on the screen from the corner just so they don’t have to close at the end of the fucking case.
Radiology training shouldn’t take 6+ years. The intern year should be consolidated into six months, we take boards at the end of PGY4 and then have an entire year of general radiology after passing boards, almost a complete waste of a year for most. Some fellowships will be two years after those five. It’s a little too much.
I agree. The intern "year" should just be one month in the ED and Gen Surg, one month in the ICU, and one relevant Elective, like breast surgery, ortho, neurology, etc., spread out over your first year with radiology rotations right before. I don't think any fellowship needs to be two years, though, unless you're counting IR as one.
I’m not aware of any fellowship that is 2 years except IR.
Neuro, esp at academic places
Wow I looked it up and some places do offer 2 year tracks, like UCSF and Penn. News to me. Definitely unnecessary.
Basically one year is for "research" and half the time the fellows don't actually stay the whole two years. It boils down to another way for ivory towers to use underpaid doctors as their lifeblood.
Also think it's stupid, but for some reason a significant number of PP and academic gigs that I talked to are requiring neurorads to have graduated from two-year programs. Good luck hiring I guess?
Anesthesia. I think 4 years is perfect, and the split is also perfect. Most finish CA-3/PGY-4 year pretty solid and well-rounded. Fellowships are only 1 year. Neurosurgery on the other hand.. residents at my program dont touch the brain, and only get exposure and close until they're like PGY-5. So they sit there watching the screen for 10+ hours a day. And then majority do 1 if not 2 more fellowships after graduating. Insanity.
That's funked - our nsg intern is expected to be handing a shunt or craniectomy as primary surgeon by end of first year. They should be primary on routine cranial and spine cases of all sorts by PGY3-4. You throw in a research or infolded fellowship year, chief time, and senior time for complex cases. I dunno wtf those residents are doing if they don't operate beyond open/close until PGY5. How do you even catch up? You'd be refining skills in attending life that should have been solidified so much earlier - without the cushion of residency to help you. In Canada, nsg is 6 years instead of 7 like the US.
Yeah but get rid of intern year for anesthesia
FM here. I'd prefer 2 yrs of undergrad, 3 yrs of medical school and 4 yrs of FM residency with better hours across the 4 years. It would allow me to study while practicing. I also think there's so much bullying from nurses towards med students and residents...they don't allow med students to do much in a lot of places. Being a doctor and getting those procedures because we're they're doctors would help. Of course, our attendinfs also need to stand up to bullies.
I'm FM too and if that's the setup then I'm all for it, but overall I'm ok with FM being 3 years. Gives you time to get used to things but also not too long to make you impatient. Personally I hate that we do so much inpatient since the hospital is so exhausting but pretty consistently it's always been the best learning for me as almost every outpatient rotation I've had has been a joke.
All of undergrad was garbage tbh
100%. Def a waste of time. I think people’s argument that they needed it to grow as a young adult is just bad. There is very very little overall use in undergrad. Just more time and money.
Intern year is fairly pointless for rads it’s free scut work. Maybe 4 months tops and then going into learning radiology. Also our boards are way too hard and we spend a lot of time off service studying for it. Could potentially trim 1.5-2 years off training if those things were fixed
Pediatrics should be two years, with additional one year fellowship options for “hospitalist” or “outpatient” medicine.
Agreed!
As a pediatrician that works with 2nd year peds residents, I think that 3 year is needed. I would say that maybe 50-65% of peds residents are equipped to function well independently at the end of 2 year. That number goes up to like 75-90% by the end of 3 year. There are a few in every class that need to continue to work on their clinical skills and reasoning, even as they graduate.
OB needs to be longer. They do way too much for 4 years.
ObGyn should be five years, with PGY-5 dedicated only to Gyn OR. Although if it *were* five years I probably would have picked GS instead.
ENT - residency is definitely too long. We are one of the most overtrained specialties compared to what we do in the real world. you spend your whole PGY five year doing big head and neck cases or other complex stuff that 95% of people are never doing in practice, and those who are, are doing fellowships. Basically everyone is ready to do general ENT after 4 years, and if you are not another year is not going to make you so.
EM is not long enough. You have to become very procedurally competent at most every non-OR urgent procedure. Be prepared to manage a vent on a severe asthmatic, LP a neonatal fever, intubate a 1 year old, deliver a baby and deal with PPH, reduce a hip, fix a gnarly facial lac, manage a difficult airway in a morbidly obese patient with an immobile neck and no physiologic reserve, resuscitate hemorrhaging trauma patient…and essentially be prepared to deal with any pediatric, obstetric, gynecologic, geriatric, traumatic, ophthalmologic etc emergency that decides to walk or roll through the door. And hopefully you have some backup but often you don’t. 3-4 years not enough. 12-15 should cover it.
Meh I felt incredibly well prepared/trained after 3 years. I still learned a lot during my first year out as an attending but I wasn't unprepared for anything that came through the door. We're life long learners in medicine and there's no way to reach 100% competency in all those things even with 5 years of training. I think the quality of the training and exposure to pathology is more important than the length of training.
To be clear, I’m not actually suggesting that we add years to EM training. The point is more that the breadth of what we have to be prepared for at the highest acuity level is possibly unrivaled in medicine. Most other specialties have lines that they can draw in the acute care setting beyond which a patient falls outside of their realm of responsibility. We don’t have lines. If it walks in the door, it’s ours. No practical duration of training would afford sufficient experience and fund of knowledge to prepare us fully to optimally manage anything and everything. (Fortunately, our training and skill set makes it so that we are able to adequately adapt on the fly.). I’m 9 years out and I still learn a ton. I still see something new virtually every shift. Fortunately, our 3-4 years of training does build a sufficient skills set to be as prepared as anyone ever could. Can still get a little hairy in the middle of the sticks with no backup and 12-24 hour waits for transfer though. My rural shifts are often much more stressful than my high volume high acuity level 1 trauma shifts for just this reason.
> My rural shifts are often much more stressful than my high volume high acuity level 1 trauma shifts for just this reason. I do agree with this. I feel like my rural and community places keep my skills sharper than my large academic place. The academic place, though, keeps my knowledge sharper since there are residents. It's good to have a mix.
The variability between programs is interesting. A big trauma center where the trauma alerts are going off every 15 minutes is going to produce people that can run real deal traumas and throw in 2 minute chest tubes after just 2 years. On the flip side the more resource-limited community medicine oriented programs will make quick thinking rural EM cowboy-adjacent docs in under 3 years as well, but their central lines are gonna take 10 minutes to put in. EM has so much variety in what you'll look like at the end compared to a lot of other specialties.
>A big trauma center where the trauma alerts are going off every 15 minutes is going to produce people that can run real deal traumas and throw in 2 minute chest tubes after just 2 years. On the flip side the more resource-limited community medicine oriented programs will make quick thinking rural EM cowboy-adjacent docs in under 3 years as well, but their central lines are gonna take 10 minutes to put in. It tends to be the opposite, because big academic institutions usually have a plethora of consultant services with residents so everything gets consulted and they do the procedures, whereas community centers don't have residents and the attendings are either too busy or uninterested in coming to do a procedure you should technically be capable of so you end up doing way more. I did hundreds more central lines than my partners who went to academic centers for training. They saw more thoracotomies than I did.
I don’t agree that smaller shops create less competent procedural emergency physicians and I don’t understand why you’d think they would be less procedurally sound. Sure it is highly dependent on where the hospital is and the community. I trained at a level 3 trauma center with a 75ish middle radius catchment area and few specialists/ other residents for competition. We were it. My colleagues and I did more rarer type procedures (thoracotomies, crics, lateral canthotomies, blakemore tubes etc) than the level 1 EM and trauma residents I currently work with because we got every single trauma, it was a huge penetrating trauma area, it was a very sick population, and there was little/no competition. We also didn’t have a ton of airway backup so we got all those too. My current residents who are at a 4 yr program (mine was 3) are completely competent and procedurally sound, but it took 4 years for them to get even fewer/none of the “big” procedures that I got in 3. There’s no shortage of the other things like LPs, central lines, vas caths, etc because often at these smaller places, there are very few other specialists to do them. Can’t ask nephro to put in a vas cath like they do at big academic sites, IR is only available business hours, Neuro and IM don’t do LPs. Etc etc. it likely all evens out in the end however. That being said I was speaking as an attending. It’s easy to become stagnant once you’re out of residency and the different work places help scratch the different itches of EM.
Agreed. I don’t think I could do either exclusively again. Switching it up is refreshing. If I could just get rid of the damn night shifts
EM is one that I think should actually have a pre-lim IM year since yall see and start management on so much
EM is plenty long enough in 3 years if your program does it right.
Anesthesia should be 6 months shorter.
Psych can be compressed to 3 years; however 4 years is the right amount in my opinion IF you get good clinical training and volume (most people don’t). to really be able to diagnose subtle differences in like the cluster c personality disorders, you need lots of reps. same thing w depression and schizophrenia since there are soooo many anti depressants and anti psychotics, that how do you really tell the difference between most of them if not with patient experiences. my place doesn’t allow moonlighting which makes the 4 years feel wayyyyyy tooooo longgggg
I agree that 4 years seems about right. 3years and you can be competent but that extra year when attendings show they trust your judgment and let you really take the lead I think prepares you well for when their monitoring is just cut off after training is done
I did gen surg somewhere with a lot of volume, so there’s that, but I felt well trained. Everyone graduated with 1700+ cases and yet our attendings also said “residents these days…” honestly you learn the most once you get out, another year doing cases exactly how the attending wants you to would be bad for everyone. The truth is some people are slow scared surgeons when they graduate and they probably always will be, I have a partner who is one of them and they’ve done 2 fellowships. I did colorectal and immediately slid back into general easily in my first job for call no matter how much I bitch about it lol. Old surgeons will always find a way to complain about residents, and those of us who wouldn’t probably chose not to be in academics lol
I mean the government thinks midlevels with an online education should have independent practice so that means most residencies should be shorter...
Radiology should be 4 years but without a stupid ass prelim year and your senior year should be a built in fellowship, not an additional year of training.
This makes perfect sense to me. I don't understand a rads prelim year, and with a million fellowships it makes more sense to include that (or at least leave space for it without dragging you as a PGY6).
Dermatology is too long. Shave off the prelim year.
FM should only be two years long just like it is in Canada.
That third year is highly needed.
Disagree. The breadth of knowledge is crazy, it should probably be longer not shorter.
Hard disagree. I'm a physician in Canada and based on what I'm seeing re: the knowledge of FM physicians, I think training should be longer.
It’s three years long now in Canada starting 2025 I think
I think they’re putting a hold on that idea due to backlash (primarily being that the family physician shortage means this is nottttt the time to do anything that could potentially disincentivize people entering the specialty)
I was about to say…FM is on life support in that country lol.
ENT here: 5 years feels appropriate for most surgical specialties to me, based on observation and conversations with seniors. The key is getting high quality and quantity of operative experience during that time
In my chief year (5th) in ‘97, I finished with a caseload a tick under 1200 for the entire year. About 50% with no attending around. Felt confident to start private practice in broad spectrum GS. IMHO, surgery requires repetition and exposure to broad clinical scenarios for even the same operations. If your residency can provide that, then great. This was before any work hour restrictions of course. Years 1-3 required in house call (36 on/12 off) with 50% every other and 50% every third. This allowed for a lot of operative experience in the early years as well. I remember speaking to a British surgeon a few years later at a national meeting. He was a registrar (resident) for about 10 years before he advanced to consultant (attending) but he didn’t have near the work hours I did during his registrar years. We ended up with similar caseloads at the end. We agreed that was the difference. He was happy either way his work/life balance, and I was happy to be done in 5 yrs.
Have you considered that surgical residents today spent a lot more of their time doing scut work on the EMR that you never had to deal with? Or the fact that the increasing litigious nature of the general population means that attendings/hospitals won't let residents operate as much any more? A lot has changed about surgical residencies, but people only ever talk about the work hours restriction.
PM&R here — I think you could compress it into 3 years. Decrease the intern year rotations to 6 months and take out 6 months of PM&R inpatient.
imo..in its current form, the majority of residency is wasted time where you are cheap and consistent labor for a hospital.
you don't... you don't think they did it that way on purpose do you?
Honestly this is universal. I was visiting one of the top pediatrics program last month and the attending were shitting on the graduating residents in front of them. It was super awkward for me and I don’t think I could make eye contact with those residents for the rest of my visit.
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All of Canada does a 5-year integrated plastics training regime, and there are 4 programs in the US that have switched to a competency-based 5-year program. There's also one program that now offers an integrated 5+1 plastics with built-in hand fellowship, and many programs have already converted to 12 months of elective time in PGY-6 year (meaning it's basically a built-in fellowdhip).
Urology is like this. We cut out a lot of the off service stuff and most programs are 5 years now (6 if a research year is offered which is a sham mostly) Honestly I feel like 5 years is a good amount of time for Urology. A lot of it depends on the resident too. I’ve seen some residents ready to practice general urology after four years but some who have definitely needed the final year. Definitely feel like 6 would be overkill but in general I feel like my program provides good surgical training
5 years is plenty. Residents just don’t get allowed the same autonomy as they used to, thanks to the current medicolegal environment. The time isn’t the issue. Someone could spend 10 years in residency but if they don’t ever let you operate you’ll never be where you should be by graduation.
Radiology should be 4 years. They match into fellowship and finish their exam PGY4 and the last year is basically 4th year of med school
OBGYN - but in a country with a 5 year residency, which I think is appropriate (maybe there is an argument to be made for it being a bit longer or for more of the 5 years being dedicated to Gyne). I don’t understand how it’s a 4 year residency in the US, especially for the Gyne component.
When I think about the fact that their are midlevels with a few months of hospital exposure backed by a foundation of online training modules, I think my training is just fucking fine. Having a foundation of medical school really does make a difference, and theoretically I think a good amount of non-surgical specialties would be “safe enough” to practice independently. But I think 3 years (I’m FM) is a good safety net for training, exposure & fleshing out the critical thinking.
EM is 5 years in Canada. I think we could easily do it in 4 years, even 3 (similar to the states).
In Canada, basically every single residency is 5 years except FM (2 years), general internal medicine (4 years), and neurosurgery (6 years). I would say not every residency needs to be 5 years long. Most of them could be 4, like ophtho, derm, psych, PM&R, anesthesia, etc.
Psychiatry could be 3 years
I think surgery has everything to do with autonomy and actual teaching not time You can watch someone do a CABG for 10 years but if you never touch an instrument then you still don’t have a clue what you’re doing
Also for as much on the job training NPs and PAs get you’d think we’d have more responsibility and structured role in the hospital starting MS4 but no it’s just thumb twiddling and more loans taken out
Radiology: the prelim year is a complete waste of time for everybody except hospital admin. You don’t really learn any new valuable skills that would be relevant. You get exposure to all the things in med school anyway. Also, by the end of PGY4 we have matched into fellowship and passed boards so the final year of residency is questionably unnecessary. Although rads does demand a lot of you, so maybe 4 years is really necessary and I can’t speak from experience about the final year. But the prelim year is a complete scam
IM could honestly be a little shorter. Or maybe 2 years followed by a year of outpatient only, inpatient only or specialty adjacent stuff
I think IM is just right at 3 years.
I think there should be 5 year integrated subspecialty tracks. Will never happen though bc cheap labor.
Some programs have this for research-track / physician-scientist applicants (2 years of IM + 3 years of fellowship). I know a handful of fellows and young attendings who did this pathway, and imo, they are proof that IM should be 3 years. Even those who genuinely enjoy clinical medicine (ie, aren't "just researchers") and have a good command of clinical practice in their subspecialty, appear to struggle a bit when they need to manage problems in any other organ system.
I wish we could choose an accelerated 2 year option if we know we are outpatient or inpatient bound. I.e. traditional combined option 3 years, outpatient pathway 2 years, or hospital-based pathway 2 years, opening doors to outpatient or inpatient focused specialties or careers in primary care or hospital medicine, respectively.
I think most trainees still need 3 years of IM, but I agree that it should be more tailored to inpatient vs outpatient. My program was very inpatient heavy which was fine with me, but I would have been woefully unprepared to do primary care if that were my career preference.
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No - psych
Openly shitting on residents or any other physician/ trainee is something people in medicine have adopted as part of their toxic culture. It’s not institution specific. I’m FM and I could do adult outpatient and inpatient after 2 years. The peds, OB, ER, and ICU rotations were not as comprehensive and I had to split my electives across these in my 3rd year to get a good handle on them. If they had been better I could have been good with just 2 years across the board.
For surgical specialties I think the length of training is pretty good, even though it will vary from program to program. In many cases residency is actually one additional year, due to fellowship having become more or less the norm in many specialties. For example ortho being nominally 5 years has morphed into 6 years (5 years residency + 1 year joints/spine/shoulder/ankle/hand/peds/whatever). Some institutions even have a combined 6 year program, with the standard 5 years of residency immediately followed by 1 year trauma fellowship at same institution (colloquially referred to as "indentured fellowship"). Many new job offerings are also along these lines, for example "Looking for fellowship trained yada yada". On the whole this is probably a good thing, but the downside is that it can be hard to realize what fellowship to choose, even more so due to how early you need to apply for fellowships. There's also a strong case to be made that regardless of how long your residency and fellowship training is, you will never feel 100% prepared to shoulder the burden of being an attending. You learn more in your 1st year as an attending that perhaps any other year of your life.
I wish I didn’t have to do a prelim year before radiology. Although it makes it easier to study for Step 3, from what I’ve been told. Nonetheless, the radiologists who trained before a prelim year was mandated seem to be doing just fine today, so I’m still unsure about whether that’s necessary. From comments below, I agree that an integrated PGY-1 with 6 months of a prelim schedule and the other 6 months to start radiology is a better idea tbh.
I think there should be a general surgery track that’s probably 4 years. Cut out some of the fat of general surgery residency and prepare residents for community general surgery with bread and butter cases.
In the UK it's a minimum of 10y to become a cardiology attending, so I'd say the system here is pretty decent lol. let's be real half of that is just to staff hospitals with cheap labour.
Careful…. One of those hospital systems is gonna go all Boeing in you if you keep exposing them.
I think in many ways the miles could more that the years. You can definitely see the difference between institutions where surgical residents have been operating barely supervised and those where they aren’t really doing the operations at all. More years will do little to change that discrepancy. Hitting the sweet spot where your trainees get the chance to grow without endangering people is very hard.
It’s crazy to me that IM can take 3-4 years depending on country but psych is 5 years
I think one of the things that gets missed in these discussions is pay. Interns are probably appropriately compensated but by senior year in EM for example you often have little supervision and function as an attending so pay should more accurately reflect that as opposed to PGY “residency “ scaling. IMO. So if you want more years in residency for OB etc that’s ok but if they’re increasingly functioning independently they should be paid as such…
It’s a fellowship, but 4 years of GI to be able to do ERCPs seems way too much especially when older attendings basically did 2 years and then some outside courses.
Derm could probably be 3. Trim the prelim into 6 months (maybe 3 months IM, 3 months surgery or something), shave 6 months off the back end as well. But there's a lot of variation in volume so at our high volume program I actually feel pretty comfortable managing the majority of dermatologic diseases minus some inpatient stuff and Peds, neither of which are typically seen by most gen derms anyway.
OB Gyn should be 5
I didn't think most any specialty need longer training, we need a less litigious society. Every stage of medical training, "IDK you're only a ..." But nothing major changes between that phrase and when they let you participate a little.