Thursday, September 11, 2014

More ratings—this time it's residency programs

Can you really decide which surgical residency program is right for you using Doximity's Residency Navigator?

I don't think so, and here's why.

The rankings of residency programs were obtained by surveying surgeon members of Doximity. They were asked name the five top programs for clinical surgery training. When the survey was announced in June, I predicted that most respondents would probably overlook the word "clinical" and focus on the usual famous academic institutions.

I also pointed out that anyone not intimately familiar with a program would be unable to judge whether it is good or not and suggested that reputation would be the main driver of results.

In fact, that is exactly what happened. Of the top 40 programs listed, all are based at university hospitals, as are 66 of the top 70. Back in June, I speculated about the top five programs and got the first two correct but in the wrong order.

A 2012 survey of surgical residents with over 4200 responders (an 80% response rate) found that community hospital trainees were significantly more satisfied with their operative experience and less likely to worry about practicing independently after graduation. Wouldn't you then expect a few community hospital programs to be among the top 40 hospitals for clinical surgery training?

Proof that the survey's findings are not reliable is that every one of the 253 surgical residency programs in the country was mentioned by one or more of those who responded. This included one program that has been terminated by the Residency Review Committee for Surgery. At least it appears near the bottom of the list.

The number of voters who cited the lower ranking programs must have been very few, meaning the difference between the 200th and 240th program ranks is probably not statistically significant.

Some programs that were rated are so new that very few or no residents have graduated yet. How could anyone know if they are turning out competent clinical surgeons?

Board passage rates for programs, which are available online, were omitted for some and were not clearly identified as the percentage of residents who passed both parts of the boards on the first attempt only.

The percentile rankings of alumni peer-reviewed articles, grants, and clinical trials are displayed prominently. What do those data have to do with the research question—which residency programs "offer the best clinical training"?

So what's the bottom line?

You can put the Doximity Resident Navigator in with the other misleading ratings of hospitals and doctors. Applicants considering surgical residencies should not rely on it for guidance.

It has warmed the hearts of faculty and residents at highly rated programs, but I wonder how the OR lounge discussions are going at places where programs ranked lower than expected.


Anonymous said...


It seems to me that you are frustrated by the answer to the question, because you believe the answer is wrong. Is it possible that it's sort of silly to even attempt to answer the question? It's like asking someone where you can get the best pizza on the East Coast. Connecticut, New York, or Jersey?? The truth is, there are a lot of great places to get delicious pizza!

What is the best model for how physicians learn how to practice surgery? One model likens a newly minted MD to a big empty bucket. As the vessel is filled with more water (learning and clinical experience), the trainee becomes a competent surgeon. The rate of filling can be increased if a trainee goes to a higher quality residency program, or maybe works longer hours.

I happen to believe in a different model, based on the observation that clinical growth continues long after residency is over; that some people who did well in medical school never figure out how to be a competent clinician, and that I've met amazing docs from "middling" programs and terrible docs from "top" programs. When we start medical school, we are given a cup and told to go fill it with a hose. There is so much information flying at us, and it is nearly hopeless to make logical sense of 99% of it (other than to purely memorize it), which simply overflows the small container. By the end of medical school, some of us are still carrying around cups, but others have progressed to jugs. But the hose is still on and the jug is overflowing! By the end of chief year, a surgical resident is carrying around a bucket, which is still overflowing because the spigot is still open.

There are dozens of awesome training programs in the USA where residents will have big case loads. We all read the same books. In five years, for 95% of us, there will still be more information flying at us than we can contain. For this to not to be the case, the individual must be truly exceptional, or the program must be uniquely terrible. As such, instead of rankings, I've always felt it was more helpful to think of residency programs in "tiers" rather than absolute ranks. I would argue that there are 50 or so high quality programs in the USA that a resident could get great clinical training at, in terms of volume and diversity. There are another 50-100 where most residents will get sufficient training.

Residents can get fantastic clinical training at Hopkins or MGH. And they can get it at excellent academic programs like U-Chicago and Cornell, which are ranked 20s-30s. But they can also get it at powerhouse midwest programs, like Ohio State, Cincinatti, Indiana, Wisconsin, Minnesota, which are only ranked in the 40s-50s. The focus on clinical training isn't helpful to applicants IMO because there are so many places where its great, good, or sufficient.

During interview events, I tell applicants they can get great clinical training a lot of places, so they should think about objective things, and think about subjective things that they care about. What are research opportunities? How many publications does the average resident produce, and of what quality? Where are they matching for fellowship? What is the city like? What are the residents like? What about the lifestyle?

Skeptical Scalpel said...

Thank you for your thoughtful comments. I like your pizza analogy. Applicants should note your last paragraph, None of the important parameters your mentioned are available on the Residency Navigator or anywhere else.

Anonymous said...

This is interesting. I also like the pizza analogy. ObGyn is not directly comparable to general surgery, but as a graduate of a community residency program, I feel it was excellent training for being a general OBG in "real life". Big name programs are likely still (I finished 19 yrs ago) important for fellowships and academic appointments, but they may even be detrimental for basic practice. Therefore, it's important to select a training program compatible with one's goals. When our residents rotated through the ivy league program for gyn-onc, we always impressed them with our (more advanced) clinical skills--it's hard to operate much as a resident when there are fellows also trying to get cases--I suspect this is worse now, with more minimally invasive surgery being done. One huge benefit of my program was an active attending staff--all of the community docs were expected to utilize the residents. Since it was a small program, we learned to operate as first assists to our attendings, not just by operating with the resident the next level above. I think this was critical. We were heavily, directly supervised, but also allowed to act as primary surgeon on virtually all cases. It was an invaluable learning experience. I (maybe naively) truly felt that I could operate independently within my comfort level, pretty much from the get-go once I finished. This is a long-winded way of saying--find out who you will be learning from!

artiger said...

I think the clinical experience and training depend more on the resident than the residency.

Skeptical Scalpel said...

Anonymous, very well put. It sounds like you had excellent training. Find out who is training you is good advice for any resident applicant.

Artiger, it has a lot to do with the resident's level of commitment and enthusiasm, but there are some very bad programs out there. I believe that it might not be possible to get a well-rounded surgical education in some of them.

And wherever you train in surgery, you must be allowed to perform cases in order to master them.

Unknown said...

The pizza analogy is more than perfect. We have the same argument about ranking of EM programs, but the well known names rise to the top. Well known pizza chains such as Papa Johns or Pizza Hut will in general turn out decent pizza, but it's the rare person that calls it the best. Similarly, there are some great pizza places that are only known to a select few. Since the overwhelming first decision in residency is geography, the vast majority of rankings are moot, and only important in the minds of a select few. Namely, the PDs themselves, and the students who self select for "the best" regardless of methods behind it.

Skeptical Scalpel said...

Justin, thanks for commenting. I agree that geography plays a big part for many applicants, and the whole subject of ratings might be important to fewer people than we think.

Anonymous said...

Skeptical, I am a third year medical student interested in general surgery. During my third year clerkship at a large academic hospital I have noticed the residents do not have a lot of autonomy in the OR. I am interested in community programs because I would like to eventually work as a community general surgeon and feel prepared to do so at the end of my residency. Since these rankings are so unreliable I was wondering if you could offer any advice as how to determine which programs would be suitable for my goals. Are there any community programs in specific that you think highly of?

Skeptical Scalpel said...

The only way that I know to find out what a program is really like is to speak to one or more of its current residents. I suggest you make a list of a few programs, call the hospital page operators in the evening, and ask to speak to one of the surgery residents.

I'm not sure whether this will be well-received, but it's worth a try.

Since I haven't spoken to many residents lately, I have no current knowledge of programs. I wish I did.

artiger said...

Scalpel, as an aside to add to your advice above, it might be advisable for the student to ask one of the residents at his/her current program if they know anything about some of the community programs, or better yet, if they have friends who are residents in those programs. That might be a good way of getting in touch with someone at those community programs.

Skeptical Scalpel said...

Agree. No harm in asking residents. They may have even visited a program the student is interested in.

Anonymous said...

Umm. I have to strenuously disagree with the plan of paging the on call resident. As a junior resident who takes a lot of call, I would be less than receptive to being paged by a medical student who I had never met and to whom I did not provide my contact information.

Email is nice though - and our emails are usually posted on our program's website. You can also email the program coordinator who can set you up with someone to email.

Skeptical Scalpel said...

Drinking, I appreciate your comment, but would you or any other resident be willing to say anything negative about your program in an email? I doubt very much that you would. I understand that you might be busy, but how about telling the caller you will get back to her when you have a few minutes? It would be worth your time to speak to any applicant. Don't you want to recruit the best people you can?

Anonymous said...

I'm trying help out some naive medical students who could REALLY shoot themselves in the foot by cold-calling busy surgical residents on call. the on call resident is usually the person who is least happy to randomly chat with medical students since I may be in the midst of seeing a consult, scrubbed in the OR, etc.. personally, I would respond less well to being paged during hour # 30 of my workday (yes, i know) than if someone emailed me at the same hour.

to your point about speaking negatively in email - if that's your belief, it would be logical to use an email introduction to set up a phone conversation. perhaps even offer to make email introductions on the student(s) behalf. that would be a respectful and appropriate method of starting a conversation with someone the students have never met.

however, as a larger point: i think getting candid information from strangers (particularly negative information) is highly unlikely, regardless of the medium.

that said, I do personally make it a point to discuss the downsides of my residency program with all of the sub-i's during their month with us ... and I would be willing to put (a carefully worded version) of that conversation in writing ...

additionally the willingness to "say something negative" can run DIRECTLY counter to the desire to "recruit the best people" - as every recruiter knows ...

Skeptical Scalpel said...

OK, an email to arrange a phone call would work. I'm just not so sure how many programs list their resident's email addresses on websites. Many program websites I have looked at don't even list the names of the residents at all.

How would you suggest an applicant get realistic information about a program? I was a PD. We only let the most satisfied residents meet the applicants on interview days.

C_Elwood said...

Sir -

Thank you for bringing this to your audience. I agree that these rankings are not useful at all for anyone seeking to apply to general surgery or other medical residencies. They are no better than a popularity/name recognition contest. If an applicant needs Doximity to rattle off the 10 most well-recognized programs in their field...well, I feel sorry for that person.

My field, Emergency Medicine, has spoken with a unified voice about this. No matter the program, even the 'Top 10', we are not using or referencing these rankings in recruitment or other avenues. You can see ACEP's press release here.

Do you think other specialities will follow suit?

Skeptical Scalpel said...

C, I had seen that that link about the 9 EM doc organizations meeting with the Doximity people. I am not aware of any other specialty expressing concern. I did, but of course do not speak for the American Board of Surgery or the RRC.

Maybe no one else cares.

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