More about offshore med schools and residency prospects

Back in April, I blogged about the prospects for graduates of Caribbean medical schools matching in categorical surgical positions and estimated that graduates of two of the more prominent Caribbean schools, St. Georges and Ross, had a 2.5 to 3% chance.

What about some of the other Caribbean schools? Hard data are difficult to obtain since most of the schools do not publish match statistics, and in particular, the number of graduates who dont match in any specialty.

Here is what one recent commenter on that April post had to say:

My girlfriend studied at University of Medicine and Health Sciences (UMHS)-St.Kitts in the Caribbean. She is a very hard worker and studied well. All of my savings are gone and extra bank loans add up. No match, no residency, and no more hope. Applied for medical lab tech and waiting. In my opinion, IMG is not an option, try local medical schools and if not try something else.

The UMHS website says 59 of its graduates matched in a specialty in 2014, 2 in preliminary surgery and 2 in general surgery, presumably categorical. The number of graduates of UMHS is not listed although the school apparently has three graduations per year reflecting its three different starting dates for students per year.

Another school, Medical University of the Americas on the island of Nevis, had about 90 matched graduates for 2014, 2 of whom obtained positions in surgery—both preliminary.

An additional commenter on my April post, who turned out to be the owner of a different Caribbean school, said this:

Caribbean medical school is best platform and nice and informative….. Successful communication is key in every successful business…. Understanding your subject and having good knowledge on your blog topic is always essential for a successful blog… Thanks for this post…..

Normally I would have blocked this comment as spam, but before I did so, I googled his school, the American Global University School of Medicine, located in the Central American country of Belize. The International Medical Education Directory lists its total enrollment as 100 students. The schools website does not provide any details about match results for its graduates or much of anything else, such as names of faculty or specific hospitals where students do clinical rotations in the US.

I found some other interesting links—too many to list here—about the school, its officials, and its standing in Belize. You would be wise to google it too, or you can see some links in my comment to the schools owner on my April post.

If you have any interest in attending this or any other school not accredited by the Liaison Committee on Medical Education (LCME), you should do a thorough Internet search before going ahead with an application. Do not send money unless you are certain that the school is legitimate and that most of its graduates are obtaining residency positions.

Keep in mind that the number of residency slots available for international graduates will decline even further over the next few years because several new US medical schools will be producing graduates, and many established schools have expanded their classes.

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A paper of mine was published Did anyone read it

An orthopedist asked me if I could explain why a couple of papers of his did not generate any feedback. He wasnt even sure that anyone had read them. He enclosed PDFs for me.

Not being an orthopedist, I cannot comment on their validity.

But I think I can explain why the papers have not created much interest.

Are you familiar with the term "impact factor"? If not, here is a link explaining what it is:

A journals impact factor is an indication of how widely cited its articles are. One can also assume that it is a good indication of how popular the journal is and by inference, how many people read its papers. The impact factor has been criticized, but it is one of the few measures of a journals influence.

The two papers in question were published in Orthopaedics & Traumatology: Surgery & Research. A list of the top 40 orthopedic journals ranked by impact factor in 2013 showed that it ranked 37th with an impact factor of 1.061. That means the average number of citations for any paper published in OTSR was about 1, and 36 orthopedic journals were more widely cited than OTSR.

A paper in Physics World claims that that 90% of published papers are never cited and 50% are never read by anyone but the authors and the journals peer reviewers. I believe this is true of papers in medical journals too.

I was unable to obtain any figures regarding the number of subscribers to OTSR, but I suspect it is not large. This may also account for the lack of responses to the papers. My own experience is similar. It was very rare to receive any feedback about any of the over 90 peer-reviewed papers, editorials, or reviews that I had written.

Consider this. A blog post of mine "Appendicitis: Diagnosis, CT Scans and Reality" which I wrote 4 years ago has received over 19,600 page views and more than 100 comments. I am certain that post has been read far more than all of my published research papers combined. In fact, my 550 blog posts have recorded over 1 million page views.

What does it all mean?

Journals may have to adapt and become more like blogs. In the future, medical information may be disseminated by blogs and comments rather than journal articles and letters to the editor.

Will scientists CVs be valued more for the number of page views their papers receive than the number of peer-reviewed papers they publish?

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More germs Planes desks and even kisses

Airplanes are so permeated with bacteria that it is truly a wonder that anyone survives a flight. Ill bet you thought it was the air in the cabin, but a recent story in USA Today says otherwise. "The real problems lie on the chair upholstery, the tray table, the armrests and the toilet handle."

What should germophobic passengers do? "First, they should travel with and use an alcohol-based hand sanitizer. They should also travel with a small pack of disinfectant wipes," said the microbiologist who did the study. "The first thing I do when I sit down is to wipe down the armrest and tray table because thats where my arms will be. You need to decontaminate where youll be spending your time and eating."

From MailOnline: "Millions of us spend our days slaving over a keyboard. But lurking between the keys, hidden on the mouse and nestled in your phone lies [sic] more than 10 million bacteria—400 times more than on the average toilet seat." [Despite what I reported in my last post, the toilet seat will remain the gold standard for comparing contamination levels until it is unseated.]

At least that is way fewer bacteria than the next study found.

"Every Kiss Begins With 80 Million Germs" headlines WebMD about a paper published in the journal Microbiome. WebMD story says, "In one experiment, the researchers gave 21 couples a probiotic drink containing bacteria before they kissed. Swab samples afterwards showed the transfer of those 80 million germs."

From the methods section of the paper: "One of the partners was invited to consume 50 ml of a probiotic yogurt drink containing L. rhamnosus GG, L. acidophilus LA5, and B. lactis BB12 [all non-pathogens]. After 10 seconds, saliva and tongue swabs were collected from this partner (donator) and after a second intimate ["full tongue contact and saliva exchange"] kiss of 10 seconds, saliva and tongue swabs were directly collected from the other partner (receiver)."

Saliva has some antibacterial properties. Maybe the researchers didnt wait long enough to test for bacteria after one of the partners drank the yogurt? People who have 80 million pathogenic bacteria in their mouths probably have bad breath and poor oral hygiene. I doubt they are indulging in 10 second tongue kissing.

And heres an excerpt from the conclusion. "This study indicates that a shared salivary microbiota requires a frequent and recent bacterial exchange and is most pronounced in couples with relatively high intimate kiss frequencies of at least nine intimate kisses per day [my emphasis] or in couples sampled no longer than 1.5 hours after the latest kiss."

Ten second kisses? Nine intimate kisses per day? Other than perhaps high school kids, who is kissing 9 times a day for 10 seconds at a time?

Bottom line? After eating yogurt, wait at least 90 minutes before tongue kissing someone.

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A high school student has questions about a medical career and pathology vs surgery

A female high school student asks about pathology, surgery, and medicine in general. [Email edited for length.] See if you agree with my answers.

The field I am most interested in is pathology. I have a very logical mind and would enjoy being able to solve the complex puzzle of disease. I would also like the somewhat flexible hours compared to other more intensive specialties. However, I do have some qualms.

Im also interested in general surgery. I would love to learn how to perform all the different types of surgeries that surgeons perform. If I were to be a pathologist, would it be "knife-free"? Pathology really intrigues me, but participating in the occasional surgery sounds like it would be extremely interesting and full of learning opportunities.

There is some knife wielding in pathology. Specimens must be properly cut, and there is the occasional autopsy. However, its definitely not surgery.

What does a pathologist really do? Ive looked at various descriptions online, and none of them seem to be very specific. What would a typical day look like for a pathology resident? I was also wondering what types of skills pathologists are taught?

Pathologists spend most of their days looking at specimens, mostly microscopic slides. Here is what pathology residents at Johns Hopkins learn.

I know that medicine is constantly evolving. With new medical technology, certain fields will soon become obsolete. Do you think this will happen to pathology?

I suppose there will be some technical advances that might involve automated digital reading of pathology slides, but I believe there always will be a need for pathologists. A residency position in pathology is much easier to obtain than one in general surgery.

Since Im interested in both pathology and general surgery, I was wondering if there was a way I could do them both (in a combined program or something like that). I know this is highly unlikely.

It cant be done.

I am a very anxious person. Specifically, I have health anxiety. (Im all too aware of the irony). Do you think that the amount and intensity of the material covered during med school and residency could take a severe toll on a persons mental health?

I think every medical student at some point worries she might have a disease she just read about. Im not sure what to tell you because I am not a psychiatrist, but studying diseases for four years and having a health anxiety might be a problem.

I would also like to know whether being involved in medicine could dramatically alter a persons personality by magnifying their negative characteristics. I am very driven, hard-working, ambitious, logical, easily annoyed/frustrated, and sometimes easily distracted. Im quite anal-retentive and OCD. Some of my friends and family have described me as an emotional robot. How do you think these characteristics would be affected by a journey through medicine?

Many medical students and residents become less empathetic and more jaded as they go through medical school and residency. Except for being easily distracted, many of your traits are common in med students. Heres more about empathy and medical students.

Do you know how difficult it is for Canadian students to get into American med schools? Or do you know any medical schools abroad in English speaking countries (e.g. Scotland, England) that would be willing to admit international students? Also, would it be more difficult for a woman?

Its not easy. Here is a link to a website that has some data on Canadian applicants to US schools. I dont know much about UK schools. Ive written about Caribbean schools. Type "Caribbean" in the search field of my blog. Being a woman wont matter.

How would medicine affect interpersonal relationships? Im really close with my immediate family, and it would be difficult not being able to see them all the time, let alone during holidays or breaks. How can a person manage a serious relationship and medicine at the same time?

It can be done, but it takes some effort. I have written a few posts about so-called work-life balance.

Choosing a specialty is difficult
More about choosing a specialty
Anguish about choosing a specialty
Surgery and work/home conflict

I hope this helps. Good luck.

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The best general surgery residency programs for clinical training

Ive received a couple of emails from Doximity [A closed medical "community" of > 280,000 doctors] reminding me to complete a survey which they are sponsoring jointly with U.S. News & World Report. They are asking members, possibly only surgeons, to name the best general surgery training programs in the country.

Not mentioned in the email but stated at the beginning of the survey is that they want respondents to name the 5 best programs for clinical training.

I have a feeling that not everyone will notice the part about clinical training, and we will get a list of the usual suspects just as we do every year with the U.S. News best hospitals survey.

For several reasons, the survey is fundamentally flawed.

There are 240 general surgery residency programs in the country. Unless one is personally involved with a program, it is impossible to judge the competency of its graduates. How would I or anyone else who does not work there know whether residents training at UCLA or Baylor or Lehigh Valley are clinically competent?

There are no accepted ways to judge the clinical skills of any surgeon. Video recording of procedures with judging by peers can assess technical ability, and as shown in the recent New England Journal paper from Michigan, there is some correlation with outcomes.

The American Board of Surgery publishes first attempt board passage rates for all programs, but passing the boards does not necessarily equate to clinical skill.

Most surgeons have probably encountered only one or two graduates of any of surgical residency. Even if the ones we have seen were great, they may not represent the majority of graduates.

Ill bet I can name most of the top 5 programs right now. These are not necessarily the programs that produce the best clinically trained residents.

Here are my guesses: Massachusetts General, Johns Hopkins, Mayo Clinic-Rochester MN, New York Presbyterian-Columbia, Cleveland Clinic.

In the past, some institutions on my list were rumored to be terrible places to learn to perform surgery because the residents did a lot of watching and retracting but not much operating. Whether that is true today or was so in the past, I could not tell you.

I guarantee you that no community hospital will rank in the top 20 [maybe top 50] despite the fact that such hospitals produce many fine clinical surgeons.

I have no idea which programs produce the best clinically trained surgeons. After the Doximity-U.S. News survey results are published, you wont know either.

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Externships or observerships Can they help an IMG get a surgical residency slot

A woman writes [some non-essential details have been changed to preserve anonymity. Permission to post this was obtained.]:

I am a non-US citizen medical graduate from The University of The West Indies in Trinidad and am currently an intern in a Caribbean nation. Although UWI has produced great students, you may not be familiar with it.

I would like to become a surgical resident in the US. I have no US clinical experience, but my USMLE Step 1 score was >235.

What do you think about my doing a post-intern year externship (hands on clinical) as opposed to an observership (just observing) in the US? I know that an externship carries more weight as far as applications go, and the only reason I would want to do either of these would be to get recommendation letters from surgeons in the US.

However, since I have already graduated from medical school, getting into an externship will be more difficult because this will no longer be a medical school rotation. I believe that observerships will be easier to get into but are they worth it?

Do you know of any IMG-friendly programs that facilitate this? Do you think that this is a good idea? Do you feel that I will be able to get an externship?

Other than this idea for externship/observership, I am blank for ways to improve my chances of matching to a US program in surgery. Do you have any suggestions?

Thank you for writing and for reading my blog.

Your USMLE Step 1 score is excellent, but as you stated, the lack of any clinical experience in the US might be a problem.

Im afraid your plan to do externships may not work out. I do not know of any hospital in this country that supports externships for people who have already finished medical school. The issue is that once you graduate from medical school, you no longer have status as a student. There are medicolegal, educational, and funding considerations that I do not think can be overcome.

I am not sure about the availability or value of observerships. My opinion, which may not be shared by others, is that I see no value in observing. How could anyone write a meaningful letter for you if all you did was watch other people take care of patients?

I am also unable to tell you what a letter from a surgeon who works at a hospital nobody knows is worth.

I hope my readers will have some thoughts for you.

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Can cholecystectomies safely be done at night

A new study from surgeons at UCLA found that laparoscopic cholecystectomies done at night for acute cholecystitis have a significantly higher rate of conversion to open than those done during daylight hours.

Nighttime cholecystectomies were converted 11% of the time vs. only 6% for daytime operations, p = 0.008, but there was no difference in the rates of complications or hospital lengths of stay.

The study, published online in the American Journal of Surgery, was a retrospective review of 1140 acute cholecystitis patients, 223 of whom underwent surgery at night.

The authors advocate delaying surgery until it can be done in the daytime, but this conclusion needs to be examined.

Although the percentage of gangrenous gallbladders was similar in both groups, it wasnt clear from the data how many patients were semi-elective and how many were true emergencies.

Operative procedure durations were 110.5 minutes for nighttime and 92.4 minutes for daytime cases, and 1.5 and 2.0 days elapsed respectively before the patients were taken to the operating room, both p < 0.0001. The hospital lengths of stay were similar at 3.7 days for the night group and 3.8 days for the day patients. The causes for these lengthy operations, delays in operating, and long hospital stays were not explained in the manuscript.

The authors acknowledged that patient follow-up was no better than 50%.

Unreported confounders such as variations in the level of skill of the surgeons or whether or not a resident did the procedure could have influenced the results.

Another recently published study from the University of Texas Health Science Center in Houston found that although there was a slight but significant increase in complication rates [mostly retained stones and superficial wound infections] for patients having cholecystectomies at night, conversion rates of day and night surgery were similar.

Durations of operations averaged about 80 minutes [a more realistic figure than those in the UCLA study] in both groups. Hospital lengths of stay were significantly shorter [2 days vs. 3 days] for the nighttime patients. The authors acknowledged that a limitation of their study was that severity of gallbladder disease was difficult to accurately assess.

The decision about timing of cholecystectomy for acute cholecystitis depends on the availability of operating rooms, the severity of illness, the presence of comorbidities such as diabetes, and the surgeons schedule and other responsibilities.

Most surgeons agree that the sooner patients with acute cholecystitis undergo surgery, the more quickly they will recover and get back to normal activities.

In my own practice as a solo community hospital surgicalist taking care of emergency cases only, any patient with acute cholecystitis who I was consulted on before 6 or 7 pm had surgery that same night if an OR was available. If not, they always had the operation within 24 hours. The length of stay (LOS) averaged under 48 hours and the median LOS was 1 day.

Because one of the two hospitals involved in the UCLA study is a major trauma center in Los Angeles, the papers findings may not apply to other institutions where nighttime OR availability may be better.

Based on these papers, surgeons and patients should not be wary of undertaking cholecystectomies during evening hours.

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Board passage rates and residency program quality

On my "Ask Skeptical Scalpel" blog, a medical student wonders if a programs board passage rate is a good measure of whether its graduates can practice independently.

You can read that post here.

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Readmissions Sometimes its the patients

My Twitter friend Dan Diamond (@ddiamond) posted a picture of a slide that said a hospitalized patient was taught to inject insulin using an orange to practice on. When he was readmitted to the hospital with a very high blood sugar, it turned out that instead of injecting himself at home, the patient was injecting his insulin dose into an orange, and then eating it.

Weve all heard stories about patients who took suppositories by mouth instead of the way they were intended.

Since doctors get blamed for just about everything, some would say that patients who take suppositories by mouth or eat an orange filled with insulin do so because they were not properly taught by their doctors (or nurses).

I have blogged before about the problem of who is at fault if patients do not follow up. Although I feel that much of the time its the patient who decides not to return for follow-up, it seems prevailing sentiment and possibly even the courts say its the physician who should be held responsible.

But how do you explain this? A study in Heart, a BMJ journal, found that of 208 hypertensive patients referred to a clinic for suboptimal blood pressure control, 52 (25%) were either completely or partially non-adherent [aka non-compliant] with their antihypertensive medications as determined by urine mass spectrometry.

The authors concluded that urine testing for medications or their metabolites would help doctors avoid ordering unnecessary investigations for patients whose blood pressures were not well-controlled.

The reasons for patient non-adherence were not mentioned. Could all 52 patients not have been told about the importance of taking their medications? I doubt it.

You might think the 15% who were partially non-adherent may have forgotten to take the drugs occasionally, but it turns out that most of those in this group took adequate doses of most of other their prescribed medications. This suggests that they selectively omitted some doses of one or more drugs.

The only explanation I can fathom for the 10% who had no traces of any BP meds in their urine is that they just said "to hell with it" and didnt take their meds at all.

I know someone with type 2 diabetes who doesnt watch her weight or what she eats and doesnt check her blood sugars. She says, "Youve got to die of something. Id rather live my life the way I want to."

Is it that doctors and nurses arent educating the patients or are the patients at fault?

The answer to this question has important implications because of the newly established financial penalties for hospitals with high readmission rates.

Older methods that may improve adherence are tracking prescription refills and having pharmacists or nurses specifically assigned to explain medications to patients in detail.

Heres something that might help.

A recent meta-analysis showed that adherence to HIV/AIDS antiretroviral therapy was modestly improved when patients were sent reminders to take their medications by text message. Those who were more adherent had lower viral loads and better CD4 counts.

Of course, such an intervention assumes that patients have mobile phones or pagers capable of receiving texts, will check for messages, and will act upon the advice. Compared to patients with HIV/AIDS, those with hypertension might tend to be much older and possibly not as technologically savvy.

So what is the solution? I dont know, but sometimes the problem is the patients.

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Pain is not the 5th vital sign

No, contrary to what you may  have heard, pain is not the 5th vital sign. Its not a sign at all.

Vital signs are the following: heart rate; blood pressure; respiratory rate; temperature.

What do those four signs have in common?

They can be measured.

A sign is defined as something that can be measured. On the other hand, pain is subjective. It can be felt by a patient. Despite efforts to quantify it with numbers and scales using smiley and frown faces, it is highly subjective. Pain is a symptom. Pain is not a vital sign, nor is it a disease.

How did pain come to be known as the 5th vital sign?

The concept originated in the VA hospital system in the late 1990s and became a Joint Commission standard in 2001 because pain was allegedly being undertreated. Hospitals were forced to emphasize the assessment of pain for all patients on every shift with the (mistaken) idea that all pain must be closely monitored and treated .

This is based on the (mistaken) idea that pain medication is capable of rendering patients completely pain free. This has now become an expectation of many patients who are incredulous and disappointed when that expectation is not met.

Talk about unintended consequences. The emphasis on pain, pain, pain has resulted in the following.

Diseases have been discovered that have no signs with pain as the only symptom.

Pain management clinics have sprung up all over the place.

People are dying. In 2010, 16,665 people died from opioid-related overdoses, a four-fold increase from 1999 when only 4,030 such deaths occurred. And the number of opioid prescriptions written has doubled from 109 million in 1998 to 219 million in 2011.

Meanwhile in the 10 years from 2000 to 2010, the population of the US increased by less than 10% from 281 million to 308 million.

Doctors are caught in the middle. If we dont alleviate pain, we are criticized. If we believe what patients tell us—that they are having uncontrolled severe pain—and we prescribe opioids, we can be sanctioned by a state medical board or even arrested and tried.

Some states now have websites where a doctor can search to see if a patient has been "doctor shopping." I once saw a patient with abdominal pain in an emergency room. After looking up her history on the prescription drug website, I noted that she had received 240 Vicodin tablets from various doctors in the four weeks preceding her visit.

Thats a lot of Vicodin, not to mention a toxic amount of acetaminophen if she had taken them all herself during that month.

What is the solution to this problem?

I dont know, but as long as pain is touted as the fifth vital sign, I do not see it getting any better.

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What about a rural track surgical residency program

Heres an email from someone interested in rural surgery:

I am a senior medical student planning on going in to general surgery and practicing in a moderate sized city (~70k people), but would also like to do some medical missions. I currently do not plan on doing a fellowship after residency, and would like to go directly into practice. I have seen a growing trend of "rural programs” popping up including Mayo starting a rural track this year, Wisconsin has one rural spot, and Gundersen is another notable program. For many of these programs you leave your primary training hospital during PGY3-4 and go train rural hospital, you may also spend more time doing OB/GYN cases or other surgical specialties. How do you think this affects the preparedness of the residents leaving these programs vs a community program with a high case load or university program? Most of these programs advertise all the “extra” skills acquired from participating in their rural tracks but don’t discuss what that means you will miss.

Great question. I have no personal experience with rural track surgical programs. From what I have read, most residents who go this route emerge satisfied.

I think you need to speak to a few residents who have done it and see if they feel they missed anything. It probably wouldnt be too hard to get some names from coordinators in programs that have the rural option.

My concern for your situation is that if you plan to practice in a city of about 70,000, it is highly unlikely that you will be doing C-sections, orthopedics, or G.I. endoscopy. This would negate much of the value of doing a rural track. I have a few former residents who practice in small towns and do C-sections and endoscopies, but those locations have fewer than 10,000 people. My program provided a decent endoscopy experience, but since we had an OB/GYN residency, I think my graduates learned to do C-sections after they left the program.

Since you are planning to practice in a community hospital, you may want to consider training in a busy community hospital residency program. The way things are going in general surgery, case volume is becoming more and more important. As a general surgeon in a city of 70,000, you will probably not be doing big cases such as Whipples and major vascular surgery anyway.

Can any of my readers offer you more advice?

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More ratings—this time its residency programs

Can you really decide which surgical residency program is right for you using Doximitys Residency Navigator?

I dont think so, and heres 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. Wouldnt you then expect a few community hospital programs to be among the top 40 hospitals for clinical surgery training?

Proof that the surveys 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 whats 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.

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How to rank surgical residency programs

In September, Doximity, a closed online community of over 300,000 physicians, released its ratings of residency programs in nearly every specialty. Many, including me, took issue with the methodology. Emergency medicine societies met with Doximitys co-founder over the issue and echoed some of the comments I had made about the lack of objectivity and emphasis on reputation.

I wonder if it is even possible to develop a set of valid criteria to rate residency programs. Every one I can think of is open to question. Lets take a look at some of them.

Reputation is an unavoidable component in any rating system. Unfortunately, it is rarely based on personal knowledge of any program because there is no way for anyone not directly involved with a program to assess its quality. Reputation is built on history, but all programs have turnover of chairs and faculty. Just as in sports, maintaining a dynasty over many years can sometimes be difficult. Deciding how much weight should be given to reputation is also problematic.

The schools that residents come from might be indicative of a programs quality, but university-based residencies tend to attract applicants from better medical schools. The other issue is who is to say which schools are the best?

Faculty and resident research is easy to measure but may be irrelevant when trying to answer the question of which programs produce the best clinical surgeons. Since professors tend to move from place to place, the current faculty may not be around for the entire 5 years of a surgery residents training.

The number of residents who obtain subspecialty fellowships and where those fellowships are might be worthwhile, but would penalize programs that attract candidates who may be exceptional but are happy to become mere general surgeons.

Resident case loads including volume and breadth of experience would be very useful. However, these numbers have to be self-reported by programs. Self-reported data are often unreliable. Here are some examples why.

For several years, M.D. Anderson has been number one on the list of cancer hospitals as compiled by US News. It turns out that for 7 of those years, the hospital was counting all patients who were admitted through its emergency department as transfers and therefore not included in mortality figures. This resulted in the exclusion of 40% of M.D. Andersons admissions, many of whom were likely the sickest patients.

The number and types of cases done by residents in a program have always been self-reported. The Residency Review Committee for Surgery and The American Board of Surgery have no way of independently verifying the number of cases done by residents, the level of resident participation in any specific case, or whether the minimum numbers for certain complex cases have truly been met.

So where does that leave us?

Im not sure. I am interested in hearing what you have to say about how residency programs can be ranked.

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