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response to a reader

While I was away on vacation, a reader emailed me the following question:

Hey Mudpudder….I am in a combined BS/MD program in NYC and I really need your advice. I am asking you for advice because you are one of the few physicians I have encountered that are honest and open about their profession.  As mentioned before, I am in a BS/MD program that allows me to complete my undergrad and 2 years of my medical education at a University and the last 2 years of my medical education (rounds) have to be completed at a participating medical school. Now I just finished interviewing at SUNY Downstate, SUNY Stony brook, and NYU. They all have their pro’s and con’s.  My main goal for the last 2 years of medical school is to learn as much as I can from the wards, so that I can really decide what type of residency to apply for. Essentially, I want experience so that I can make the best decision regarding the residency to pursue. However, I am not too sure which medical college is right for me.
 NYU med is a world renowned institution with a lot of NIH funding, prominent faculty, with high tech facilities, etc. Most of all it is in NYC, so I will be exposed to a diverse population with different medical needs. However, it is a really expensive school and affiliated with mostly private hospitals. I do not know if I would really get a chance to practice my clinical skills in a private hospital. I have heard that private hospitals limit medical student/patient interactions because we are a liability. Is this true? SUNY Downstate is located in an underserved community in Brooklyn.  In addition, it is affiliated with mostly city hospitals and most of the hospitals are understaffed, so I know I will get a lot of experience. However, Downstate does not have as good of a reputation as NYU or Stony Brook in terms of research funding, facilities, etc. I am afraid that the reputation of my medical school I attend may negatively affect my residency match process in the long run. I want to do my residency in an institution that is renowned for whatever residency I choose. Does the name of your medical college have a big impact on your match process? As for Stony Brook, it is a great school that is expanding drastically in terms of research and is making a big push to attract prominent faculty. However, it is in the middle of nowhere and its affiliated hospitals serve a racially homogenous population. So I do not think I will be able to experience as many clinically diverse medical cases as I would as in an urban hospital. Now that I told you about all the factors revolving around my decision, what advice can you give me? If you were in my shoes, which medical college would you pick? And why?

First of all, I won’t tell you which medical school to pick, only what kind of logic I’d use to make the decision. 

What is the purpose of medical school?  In my opinion, to 1) prepare you for residency and 2) get you to residency. 

Your question touches on both of these points.  Let’s tackle number 1 first.  Where would you get the best preparation for residency?  Well that’s broken up in two parts too: the academic training and the clinical training.  You seem to be focusing more on the clinical training part.  Yes it is true that medical students (as do residents) get less hands-on experience at private hospitals compared to academic or low-income community hospitals.  Think about it this way, the more that patients pay, the more they expect the attending to do and the more they get pissed off when a medical student sticks them 5 times to get an IV in.  You know what I mean? 

However, it is my personal feeling based on my experience and those of friends as well as other residents is that the clinical training you get in medical school is, in general, pretty minimal.  Really.  Sure there are differences between the experience you get at different schools, but how big are those differences?  So you get to do a few more procedures at one place vs. another.  So what?  Putting in one central line vs. five or ten as a medical student under supervision of a resident still equates to zero when you start internship and you become submerged in that stuff all of the time.  There may be varying degrees of comfort between interns at the start, based on where they went to medical school, but those differences become virtually indistinguishable after one to two weeks of internship.  It’s actually quite interesting.  At no medical school will you be the intern or the resident.  Simply because you will be a medical student.  You will not spend your days doing procedures anywhere because the residents will be doing them since they need the experience more than you will as a medical student.  Make sense?  You will occasionally get thrown a bone as a medical student, which may depend on where you are training (e.g. community hospital vs. academic hospital) but again, I wouldn’t put this too high on my list of factors determining where I go to medical school.  In terms of procedures, the only thing I can think of that you should be sort of comfortable with after finishing medical school is suturing/tying knots and that’s only because you will have to do it to some degree in every residency.  Again, you don’t even need to be good at it–no one I know was good at it at the beginning of internship–just be familiar with it. 

When you start internship and you have to do pleural taps, put in central lines, suture, etc, you will do it so many times (initially under supervision) that it really won’t matter where you went to medical school.  If you want to get good at some of these things during medical school, it will mostly fall on you to practice (what you can) outside of school.  So to put it more directly, I don’t believe that going to any one of those schools that you named will give you any significant additional exposure to doing procedures.  Where the quality of your medical school plays a role in these procedures is in terms of what kinds of colleagues and residents you will have around you to teach you or to bounce ideas off of.   I learned a lot of useful tips from my residents or other medical students.

More along this route, the facts you need to learn are pretty much the same no matter where you go to school, right?  The side effects of an ACE inhibitor are the same whether you go to school A or B.  And you will have to work equally hard to memorize all of that stuff.  However, the more collegial the environment and the higher quality of medical students/residents that you surround yourself with, the more likely it is that you will get tipped off on that useful pnemonic or website that will help you to learn X, Y or Z. 

Finally, the name of your medical school does make a difference for residency applications.  It’s kind of bullshit that it should, but on some level it makes sense.  It’s bullshit because, in my opinion, the top performers at any medical school can usually always compete with each other (i.e. the top medical student at small medical school is usually in the same league as the top medical student at big-time medical school).  So I find it unfortunate when top medical students from smaller schools are passed over, especially for lesser students at bigger medical schools.  It happens.  More practically, if you are a “good” student, which most of us are, are a big school, then you will definitely get more looks during residency interviews than a “good” student at a small medical school.  It may be unpleasant to think about but it’s true. 

You mentioned the fact that one institution you are looking at may have better research and science, etc.  I’ve argued before that this doesn’t make much of a difference for medical training.  And, I stand by that.  However, being around smart people–clinical or research–is always good.  A lot of intangible characteristics get rubbed off on you just by being around them.  So while you may not “learn” anything about the side effects of ACE inhibitors from being around top notch scientists, you will however pick up lesser appreciated/unrecognized pearls such examples of how to look at problems in different ways, how to balance clinical and research careers, how to be a collegial participant in academics, etc. (some of these will apply more than others). 

Okay, so there you have it.  I think I’ve addressed the concerns you brought up and it’s probably pretty clear which way I lean, but I think it’s more important that you see my reasoning.  Maybe you agree or disagree with some or all of my points but then you can take that into account as you make your decision. 

Moreover, if any of the readers have any thoughts, please offer them.  I’m sure this reader will appreciate it.

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3 Responses to “response to a reader”

  1. 1
    Comrade PhysioProf:

    Your correspondent has it completely wrong in relation to NYU, which is affiliated with Bellevue Hospital, a massive public hospital with an extremely diverse patient base.

  2. 2
    mudphudder:

    Actually that’s true–I had forgotten about Bellevue. And from the sounds of it (a good friend of mine was at NYU for med school), most med students who rotate there get more hands-on experience than they care for…

  3. 3
    mudphudder:

    In the case that I didn’t state it explicitly in my post or at least clearly imply it, where you go to medical school is not the most important factor in determining the quality of residency you get into. A lot of other things like GRADES or BOARD SCORES or RECOMMENDATION LETTERS or PERSONAL ACCOMPLISHMENTS matter more. But, where you go to medical school also plays into the equation too–that’s all I was trying to convey.

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