Just submitted EM residency application.

[southerndoc]

CordMcNally wrote:

4 year EM residencies are a scam. They’re good for the hospital but not for the resident. Many of them will try to sell the whole “make your own path” or “mini-fellowships” to make that 4th year seem more palatable. I don’t think I applied to any 4 year programs and I wouldn’t really encourage anyone to unless you were absolutely bound to a specific geographic area.

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Why are they good for the hospital?  The hospital has to pay for the PGY-4 salary/funding.  Emergency medicine is accredited as a three-year program by CMS, which means any additional years are a cost to the hospital.

I graduated from a four-year program, and I felt like it offered me better training.  I can see it now when we hire docs.  Those that graduate from a four-year program are more confident and quicker for the first few years when compared to three-year graduates.  Does it mean that a four-year program is required?  No.

[southerndoc]

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[Dreamgiver]

Go the program with the strongest clinical training. That’s the best financial move. It will make you a stronger doctor, which will open doors to desirable jobs and decrease bad outcomes. It might mean matching in a so so area or in a program where you work more hours. No substitute for hours behind the wheel.

[BillyBob MD]

3 yr EM grad here. Fortunate to have above average scores and matched at my first choice. I only applied to 3 year programs because I didn’t feel that the 4th year was worth it for me personally. I knew I wanted to do community EM and the $2-300k opportunity cost of that 4th year didn’t seem like a good investment for me (not to say that it wouldn’t be for someone else).

What should you look for? I think volume is important. When something interesting comes in, everyone in the department goes to see it. You learn to recognize patterns and diseases by seeing them. The more volume that goes through your shop, the more interesting things you see/learn. I didn’t apply to the program at my med school in part because the ED was small with less volume than where I practice now, and because it was in a HCOL area.

Definitely consider your benefits. Even more important if you’re married, have kids, etc. Some programs only offered health coverage for the resident, and so that pushed those programs further down the list.

Go somewhere where you feel supported and part of a family. I always knew that my PD’s and fellow residents had my back. It’s not like that everywhere.

Geography can be important. For me it was about excellent training in a low cost of living area. If your hoping to land a job in a competitive market, it definitely helps to train there. My first and current job was not in a particularly competitive location, and so training 1500 miles away wasn’t a big deal. Also consider the alumni base. I got a couple of job interviews far from my training program because there were alumni in that group. Bigger programs and older programs are going to have more alumni.

Good luck, soak it all in because it’s finally time to learn how to be a doctor!

[CordMcNally]

southernerdoc wrote:

Why are they good for the hospital? The hospital has to pay for the PGY-4 salary/funding. Emergency medicine is accredited as a three-year program by CMS, which means any additional years are a cost to the hospital.

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They're cheaper (and work more) than the alternate choice for the hospital.

southernerdoc wrote:

I graduated from a four-year program, and I felt like it offered me better training. I can see it now when we hire docs. Those that graduate from a four-year program are more confident and quicker for the first few years when compared to three-year graduates. Does it mean that a four-year program is required? No.

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The biggest difference for me with new docs is between those that did moonlighting and those that didn't.

[Tim]

OP hopefully is prepared to do some trimming. I would hope some light is shared regarding the quantity of interviews that are possible. Definitely keep notes and have a plan how you will evaluate each. After 5, they start running together.

Length of program: additional year is a serious factor. But it is only one of many. Of the 7 or 8 factors, you will come down to ranking them. The goal is to be the best and train with the best. Best is the unknown, it’s different for each physician. Where do you see yourself ending up and get the best setting for you? The harder you work and the higher volumes will serve you well.
Just be glad your not choosing between 5 & 6 year residencies. Regardless where you match, be positive and get the most out of each year.

[Jaqen Haghar MD]

If you aren’t interested in academic work, the best 3 year program is the way to go.  If you measure, at the start of the year 5, a typical 3 year program graduate + 1 year of paid clinical work, vs a typical 4 year graduate, the the 3 year program graduate will be ahead in clinical ability and financial resources.

I have a friend who is a regional director for one of the big CMGs.   After a decade of making less, traveling around filling holes and other additional duties, he made it to regional director, and still makes less than I do not working for a CMG.  He does enjoy the prestige though.  The real owners and hedge fund guys enjoy the profits.

[MPMD]

southernerdoc wrote:

I graduated from a four-year program, and I felt like it offered me better training.  I can see it now when we hire docs.  Those that graduate from a four-year program are more confident and quicker for the first few years when compared to three-year graduates.  Does it mean that a four-year program is required?  No.

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Entirely agree. It's a thing. Furthermore it's a thing that a 3 year grad is unlikely to acknowledge. It's very difficult to argue that more training doesn't equal better preparation.

Best thing I ever heard about EM is that it should be a 3.5 year residency. I think that's actually right.

 

CordMcNally wrote:

The biggest difference for me with new docs is between those that did moonlighting and those that didn’t.

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If you are in a 3 year program getting worked as hard as I think you should be over the course of those 3 years your ability to moonlight w/o breaking ACGME rules is going to be very limited.

I really don't think that 3 year w/ moonlighting is a realistic or sustainable way to advise students to be ready for a career in EM. It could result in great clinical training but that doesn't mean it's something to tell students to do.

I'm not saying that the ACGME rules are all correct, but in our program the penalty for undisclosed/unapproved moonlighting is very heavy (termination) and I think you'd find this to be the case at many good programs. We don't discourage moonlighting but we insist that it be done with the written permission of the PD and that it not interfere w/ other clinical duties or break work hours. As I said, a 3 year program should be packed with clinical experiences and leave very little meaningful time for moonlighting.

[Dilaudidopenia]

As someone who graduated from a prestigious 4 year program, I can tell you it's a scam.

It was awesome running an entire pod as a pgy4 while the midlevels saw less than half my volume and got paid more than me.

Of course a pgy4 grad will be somewhat better than a pgy3 grad. By that logic you should just train forever.

Also....regional director of a CMG? Low bar lol.

[Panscan]

I would counter and say if there was not a difference in 3 and 4 yr grads a program director of a 4 yr program would likely not acknowledge that and their bias is probably to see a difference....

Also Ed residents work less hours than other residents IMO so if they had no time to moonlight then other residents wouldn't ever

[MPMD]

Dilaudidopenia wrote:

As someone who graduated from a prestigious 4 year program, I can tell you it’s a scam.

Of course a pgy4 grad will be somewhat better than a pgy3 grad. By that logic you should just train forever.

Also….regional director of a CMG? Low bar lol.

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First point: that's just a reductio ad absurdum. No one advocates training forever. We could play with these numbers all we want and have all kinds of discussions. Maybe peds should be 1 year b/c kids are so healthy? Everyone would agree this is absurd. Heme/onc fellowship? Maybe 10 years, I mean there are an almost infinite # of cancers. Again, absurd. I just think that there are plenty of lurkers on this forum some of whom are students and I think calling a 4th year of training at a great residency program a scam is over the top, objectively wrong, and should be called out. Again, you have to insert a 4 year program here and confirm that you think they are scamming people. The University of Michigan is scamming their EM residents? UCSF is scamming? Sounds kind of silly when you put it like that.

Second point: Regional director of a profitable CMG is not a low bar dude. Medical director talent is rare, to go above that is impressive.

 

Panscan wrote:

I would counter and say if there was not a difference in 3 and 4 yr grads a program director of a 4 yr program would likely not acknowledge that and their bias is probably to see a difference….

Also Ed residents work less hours than other residents IMO so if they had no time to moonlight then other residents wouldn’t ever

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First point: it's never been studied, would be hard to study, and if it was done well no one who didn't like the conclusions would respect them. I'm telling you that there are jobs and paths available to grads of certain programs that other grads don't even ever get to know about. Honestly I think some of the 4 vs. 3 debate comes down not just to length but to program and institutional goals. I know I'm way out on the edge of this forum in academics with respect for certain institutions. It's just nearly impossible to compare 4 years at Mass General or Cincinnati to 3 years at a community program in a tiny city in the Midwest. The goals are totally different. Does that mean the resident at Mass Gen gets better at airway? Not necessarily at all. I actually think there are enormously UNDERrated 3 year programs out there that provide insane clinical training and I advocate openly for them to have much more recognition than they get.

Second point: it's not your opinion it's fact, there are specific ACGME rules about EM residents. EM residents are maxed out at 60 hrs/week in the ED, whether you agree with that or not is immaterial to the discussion. So if you are working 6x10 hour shifts or 5x12 you cannot moonlight without breaking work hours. Again, moonlighting is not the goal of residency, it's not a comparison between fields of who provides the most time for it. IM/Peds programs tend to have almost none at least in my experience.

[Panscan]

Oh. OK I didn't know about the specific rules for em, Interesting

[Dilaudidopenia]

If you're paying your pgy4s less than a first year mid-level, or really any mid-level, then yes, it's a scam.

The majority of EM programs are by far and away 3 years

EM is the only speciality with this crazy split in training length aside from some surg subs that can add a year or 2 for dedicated research time.

If you want to do academics the right play is 3 yr program plus fellowship .

[CordMcNally]

MPMD wrote:

First point: that’s just a reductio ad absurdum.

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I don't know what that means so I'm going to skip it.

MPMD wrote:

Again, you have to insert a 4 year program here and confirm that you think they are scamming people. The University of Michigan is scamming their EM residents? UCSF is scamming? Sounds kind of silly when you put it like that.

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On the flip side, if these power house 4 year programs are so great then how come they can't produce well-trained EM physicians in 3 years like a majority of programs?

MPMD wrote:

I’m telling you that there are jobs and paths available to grads of certain programs that other grads don’t even ever get to know about.

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I don't believe this is specific to 4 year programs. The one caveat is academics at a 4 year program. They're simply not going to hire someone that just graduated a 3 year residency to be an attending to a PGY-4 who is the same "age".

 

I would always encourage every applicant to really look at their future goals and see if they truly need that extra year. Most don't.

 

[snowcanyon]

It's true that the highest-ranked, reputation-heavy programs will certainly open academic doors to their residents, which is what I assume MPMD is referring to. But I don't think that's a three vs four year issue- there are many highly ranked, academically strong three year programs, too. I have a hard time seeing a Brigham grad having more opportunities than a Vanderbilt or OHSU grad. With the vast majority of EM grads not completing a fellowship, these are relatively easy to get, even at top programs. What exactly are these exclusive career paths that only four year, academic programs lead to that are unavailable to those who do three year plus fellowship? I'd be honestly curious to know, because I'm unaware of them, too.

We have rotating residents from a top academic program. I asked them how the job market was since I've heard it's tightening up. They had totally drunk the academic Kool-Aid and stated in no uncertain terms that their director and chair made sure they had jobs wherever they wanted them. They obviously had no idea how hard it is to get a job at a competitive community shop, and that academic credentials will not go far in such a situation, and can even be considered a hindrance. No one wants to hire the at-the-Brigham-award new attending, after all.

But @MPMD, we also have med students. What kind of doors would open graduating from a shop such as yours that are unavailable elsewhere?