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Selecting Your Residency Program

Written by Jeff González, M.D., Resident, Department of Medicine, Hospital of the University of Pennsylvania; AMA-MAS Governing Council, Resident and Fellow Section Representative

This topic is directed both at deciding which residency programs to apply to, as well as choosing a program after your interviews have been completed. For most of us this is a very personal decision with many variables. However, these variables can be broken down into four categories. These include: 1) Program Characteristics 2) Career Goals 3) Location and 4) Family. I hope that after looking at these sections you will have a solid framework in deciding which program offers you the best opportunity to advance your career while at the same time enjoying your residency.

Program Characteristics
On the interview trail, you will find many applicants busily taking down notes, asking questions, and sifting through brochures while others do none of this. I leave this up to you but there are several things that you should keep in mind or jot down, given your preference, about programs.

Stability. First, look at the stability of the program and the institution. In the current times of cutbacks, decreased reimbursements and mergers, it is vital that you are familiar with the finances and outlook of the institution at which your are considering training. The last thing you want to happen when you arrive to start your training, is to find that the community hospital you were hoping to spend much of you time at has been sold.

There are various ways to gather this type of information. I would start by just asking the residents. If you are not familiar with the city’s health care environment, they can tell you about recent events that have occurred in the area. During your interviews, ask about the stability of the health system and any changes that are foreseen in the future. Inquire as to the strength and weaknesses of the department and hospital. However, don’t just look at the financial stability; find out about the educational stability as well. Is there a permanent department chair? Are there any top departmental administrative changes that have occurred or are expected? How long have the program director and department chair occupied their positions?

Support. “We are here to support you!” As an applicant, this is what you are looking for -- a program that cares about your education and future. Look for evidence that a program cares about its residents. You can judge this by looking at the quality of fellowships attained, turnover rate in the program (how many residents leave/transfer after the first year), availability of mentors, number of residents that stay at the institution to complete fellowships, and departmental response to resident complaints as examples.

Flexibility. How much is there in the program? Although most programs have set schedules, some are more flexible than others. Many of you will have significant others who are also residents and who you would like to be see as much as possible during your residency. Does the program match call nights, vacation, and elective time? There are other things to look for. How amenable are they in allowing residents to change schedules to attend a conference? For residents who become pregnant during their residency, how hard was it for them to get time off?

Institutional Climate. I am referring to the political/social/work climate at an institution. We all come from varied backgrounds and we should expect institutions to have a myriad of backgrounds as well. You will find institutions that are very conservative in their ways and therefore very unresponsive to change. This could be manifested by very poor relations with the surrounding community or a lack of community outreach programs. There are other institutions, which are much more liberal, for a lack of a better word, in their actions and relationships with neighbors. If you come from a medical school that is very progressive and proactive, you might not be happy at a program where you hit a wall every time you come up with a new initiative or idea.

I have not spent much time in this discussion on finding out about call schedules, holiday breaks, vacation time, number of elective months, free meals, call rooms, parking, etc. After about interviews, they all start blending together. I’m not saying that these variables are not important, because they can be. But, most applicants do not decide to pick one program over another based on whether a television is available in every call room.

Know Your Career Goals
By the time you start looking at residencies, most of you will have started to form some kind of consensus/idea of where you would like your career to lead. The program you end up choosing will play a large role in helping you achieve these career goals. Therefore it is imperative that you plan and keep your options open. 

Academics? If you have just spent eight years getting your Ph.D. then you likely will not be looking for a rural primary care program. If you have decided to serve under privileged communities then a very academically geared program might not suit you. What do you do if you are not sure? I suggest keeping your options open by looking at a more academically oriented institution. It is always easier to transition from an academic institution to a rural community practice. It is much more difficult to complete a residency at a community hospital and then try to get into a competitive fellowship at Johns Hopkins for example. It is not impossible but very, very difficult.

Prestige/Advancement. This goes hand in hand with the above advice. A well known and regarded program will give you a better opportunity to attain a higher ranked fellowship.

The End Game. In looking at your goals in medicine I suggest that you try to start figuring out where you want to end up practicing and in what environment. If you want to settle down in New York city as a pediatric nephrologist, it does not matter much where you do your residency; you can complete it anywhere. But it is in your best interest to complete your fellowship in NYC. The main reason -- increased contacts and networking. It is easier to look for a job after fellowship if you know those working in your specialty in that area. Many job offers are not posted nationwide but disseminated within a closed circle in a community. If you are coming from Texas, you might be out of the loop.

Community Outreach. Most of us entered medicine to give back to our communities and participate in their health care. You would think that all hospitals would feel the same, but this is not always the case. For various reasons a sense of mistrust can develop between a hospital and it’s surrounding community. This can make your attempts to develop community programs or even simple events difficult. I suggest speaking with the staff at an institution: secretaries, cafeteria workers, nurses, etc. as they can sometimes be much more honest about these issues than those within a program.

Is Location Important?
This can be a straightforward variable in your decision making process, but many applicants do not analyze all the advantages and disadvantages of a specific location. Let us look at some now:

Cost. This boils down to two things: How much will you make? vs. How much are you going to spend? You have to enjoy your residency and the free time that you have during it. If you are prohibited from doing this because of insufficient funds then you are doing yourself a disservice.

Outside Activities. What is there to do in the city? Do you have access to trails if you are into mountain biking? Do they have a music symphony / opera house if you like the arts? If these or other questions such as these are important to you, then take time to consider them carefully. Remember there is life outside of the hospital.

Patient Population. I found this to be a very important part of my decision in choosing a residency. In medical school I was involved in outreach to undeserved populations in my city and wished to continue to have this opportunity as a resident. I therefore looked to train in a city where there was a large minority population and resources to work with them. Although the Mayo clinic in Rochester, MN would have given me excellent training it would not have provided me with the patient make up I was looking for.

Along with population demographics, I also recommend taking a look at the percent of minority residents and attendings in the program. Make an effort to speak with them regarding their experiences. Do they feel appreciated? Have they felt discrimination? Would they choose the same program given what they know now?

Family Issues
As residents in training we are making decisions on a program which will affect everyone in our family circle. Their needs are also important to focus on when making your decision.

Significant Other. Although we try to be “strong” trainees when it comes to how long we work and stay in the hospital, we have to think about our families. Most of us will have loved ones back home who miss us and don’t like us spending thirty-six hours without seeing us. Therefore, when it comes to looking at programs it is necessary to look at time off. Are you going to have one day off a month for the next five years?

Your family also has to live in the city where you end up in. Will they have job opportunities in their chosen profession? Will they like the city? The main thing to remember is that you will not be happy in your residency if your significant other is not!

Children. Do you want your children to grow up in this city? Are you going to be able to afford child care? Does your institution offer reduced/free child care services? What is the quality of the public school system? These questions can affect which neighborhood you will choose to settle down and live in and also affect your commute.

Camaraderie. Remember that you will be spending a large portion of the next several years with a small group of people many of whom will become very close friends. It is hard to figure out the dynamics within a program from a short interview day. I would encourage you to look further. Ask friends who are at the same institution, whether or not they are in your same specialty, to give you the “scoop” on the residents there. It is always wise to talk to any resident who went to your medical school. They are more frank with their answers. They can give compare the program with that which you have encountered in your medical school. Make an effort to contact them either on your interview day or afterward.